Value plan option

Medco Medicare Prescription Plan® (PDP) 2012 Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium, and/or co-payments/coinsurance may change on January 1, 2013.

A Medicare-approved Part D sponsor

This information is available for free in other languages. Please contact our Customer Service numbers at 1-800-758-4574; New York State residents: 1-800-758-4570 (TTY/TDD users only: 1-800-716-3231) for additional information. Customer Service is available 24 hours a day, 7 days a week. Esta información está disponible sin cargo en otros idiomas. Por favor comuníquese a los números de Servicio al cliente al 1-800-758-4574; residentes de New York: 1-800-758-4570 (sólo los usuarios de TTY/TDD: 1-800-716-3231) para obtener información adicional. El Servicio al cliente está disponible las 24 horas del día, los 7 días de la semana. This document is available in braille. Please call the Customer Service numbers listed above if you need plan information in another format.

Y0046_F00SNS2B File & Use 08032011 Formulary ID: 12031, v6 Updated 08/2011

i

What is the Medco Medicare Prescription Plan (PDP) Formulary? A formulary is a list of covered drugs selected by Medco Medicare Prescription Plan (PDP) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Medco Medicare Prescription Plan (PDP) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Medco Medicare Prescription Plan (PDP) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary change? Generally, if you are taking a drug on our 2012 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2012 coverage year, except when a new, less expensive generic drug becomes available, or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our Plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits, and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe, or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 1, 2012. To get updated information about the drugs covered by Medco Medicare Prescription Plan (PDP), please visit our website at www.medco.com or call Customer Service at 1-800-758-4574; New York State residents: 1-800-758-4570, 24 hours a day, 7 days a week. Customer Service is available in English and other languages. TTY/TDD users should call 1-800-716-3231. If there are additional changes made to the formulary that affect you and are not mentioned above, you will also be notified in writing of these changes within a reasonable period of time from when the changes are made. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition

The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular, Hypertension/Lipids.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

ii

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 35. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Medco Medicare Prescription Plan (PDP) covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Medco Medicare Prescription Plan (PDP) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Medco Medicare Prescription Plan (PDP) before you fill your prescriptions. If you don’t get approval, Medco Medicare Prescription Plan (PDP) may not cover the drug.

• Quantity Limits: For certain drugs, Medco Medicare Prescription Plan (PDP) limits the amount of the drug that Medco Medicare Prescription Plan (PDP) will cover. For example, Medco Medicare Prescription Plan (PDP) provides two inhalers (17 grams) for a one-month supply per prescription for PROAIR® HFA. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, Medco Medicare Prescription Plan (PDP) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Medco Medicare Prescription Plan (PDP) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Medco Medicare Prescription Plan (PDP) will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website at www.medco.com.

You can ask Medco Medicare Prescription Plan (PDP) to make an exception to these restrictions or limits. See the section “How do I request an exception to the Medco Medicare Prescription Plan (PDP) Formulary?” on page iii for information about how to request an exception.

iii

What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that Medco Medicare Prescription Plan (PDP) does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Medco Medicare Prescription Plan (PDP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Medco Medicare Prescription Plan (PDP).

• You can ask Medco Medicare Prescription Plan (PDP) to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Medco Medicare Prescription Plan (PDP) Formulary? You can ask Medco Medicare Prescription Plan (PDP) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover your drug even if it is not on our formulary.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Medco Medicare Prescription Plan (PDP) limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

• You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our Non-Preferred Brand Drug tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Brand Drug tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty Drug tier.

Generally, Medco Medicare Prescription Plan (PDP) will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you are requesting a formulary, tiering, or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.

iv

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our Plan, you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary, but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our Plan.

For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the Plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our Plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited but you are past the first 90 days of membership in our Plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Other times when we will cover a temporary 31-day transition supply (or less, if you have a prescription written for fewer days) include: • When you enter a long-term care facility • When you leave a long-term care facility • When you are discharged from a hospital • When you leave a skilled nursing facility • When you cancel hospice care • When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized

The Plan will send you a letter within 3 business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options.

For more information For more detailed information about your Medco Medicare Prescription Plan (PDP) prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Medco Medicare Prescription Plan (PDP), please call Customer Service at 1-800-758-4574; New York State residents: 1-800-758-4570, 24 hours a day, 7 days a week. Customer Service is available in English and other languages. TTY/TDD users should call 1-800-716-3231. Or visit www.medco.com.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or visit www.medicare.gov.

v

Medco Medicare Prescription Plan (PDP)’s Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by Medco Medicare Prescription Plan (PDP). If you have trouble finding your drug in the list, turn to the Index that begins on page 35.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., NEXIUM®) and generic drugs are listed in lowercase italics (e.g., omeprazole). The information in the Requirements/Limits column tells you if Medco Medicare Prescription Plan (PDP) has any special requirements for coverage of your drug.

Your Costs The amount you pay for a covered drug will depend on: • Your coverage stage. Medco Medicare Prescription Plan (PDP) has different stages of coverage. In each stage, the amount you pay for a drug may change.

• The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different co-payment or coinsurance amount. The “Drug Tiers” chart below explains what types of drugs are included in each tier and shows how costs may change with each tier.

The Evidence of Coverage (EOC) has more information about the plan’s coverage stages and lists the co-payment and coinsurance amounts for each tier.

If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your co-payments and coinsurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to find out what your costs are. You can also contact Customer Service for more information.

Drug Tiers

Tier Includes Helpful Tips Tier 1: Preferred Generic Drugs

This tier includes many commonly prescribed low-cost drugs.

This tier includes commonly prescribed generic drugs and may include other low-cost drugs. Use Tier 1 drugs for the lowest co-payments.

Tier 2: Non-Preferred Generic Drugs

This tier includes additional low-cost drugs.

This tier includes generic drugs and may include other low-cost drugs. Use Tier 2 drugs to keep your co-payments low.

Tier 3: Preferred Brand Drugs

This tier includes preferred brand-name drugs as well as some generic drugs.

Drugs in this tier will generally have lower co-payments than non-preferred drugs.

Tier 4: Non-Preferred Brand Drugs

This tier includes non-preferred brand-name drugs as well as some generic drugs.

Many non-preferred drugs have lower-cost alternatives in Tiers 1, 2, and 3. Ask your doctor if switching to a lower-cost generic or preferred brand drug may be right for you.

Tier 5: Specialty Tier Drugs

This tier includes very high-cost drugs.

To learn more about medications in this tier, you may contact a Medco Specialist Pharmacist at the numbers listed on the cover of this document.

Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug.

List of Abbreviations QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug. HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Customer Service. GC: Gap Coverage. We provide coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Customer Service at 1-800-758-4574; New York State residents: 1-800-758-4570, 24 hours a day, 7 days a week. (TTY/TDD users should call 1-800-716-3231.) FF: Free First Fill. This prescription drug may be provided at a reduced cost-sharing amount the first time you fill it. ED: Enhanced Drug. This prescription drug is not normally covered in a Medicare prescription drug plan. The amount you pay when you fill a prescription for this drug does not count toward your total drug costs (that is, the amount you pay does not help you qualify for Catastrophic Coverage). In addition, if you are receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for this drug. CB: Capped Benefit. This prescription drug has a capped benefit limit. MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).

vi

1

Commonly Prescribed TherapeuticDrug Categories

ANTI - INFECTIVESANTIFUNGAL AGENTS

Require-Drug Drug ments/Name Tier Limitsamphotericin b 2 PA MO

ANCOBON 3 MO

clotrimazole troc 2 MO

DIFLUCAN IN NACL 3

ERAXIS INJ 100MG 3

fluconazole in dextrose inj 0; 2400mg/200mlfluconazole susr 1 MO

fluconazole tabs 1 MO

GRIS-PEG 4 MO

griseofulvin microsize 2 MO

itraconazole 2 MO

ketoconazole 2 MO

NOXAFIL 3 MO

nystatin susp 1 MO

nystatin tabs 1 MO

ORAVIG 3 MO

SPORANOX ORAL SOLN 3 MO

terbinafine tabs 1 MO

VFEND IV 3 MO

VFEND SUSR 3 MO

voriconazole 2 MO

ANTIVIRALSacyclovir caps 1 MO

acyclovir inj 500mg 1 MO

acyclovir susp 1 MO

acyclovir tabs 1 MO

amantadine 2 MO

APTIVUS CAPS 5 MO

APTIVUS ORAL SOLN 5

ATRIPLA 5 MO

BARACLUDE ORAL SOLN 3 QL(1890per 90 days)

MOBARACLUDE TABS 3 QL(90 per

90 days)MO

Require-Drug Drug ments/Name Tier LimitsCOMBIVIR 5 MO

CRIXIVAN CAPS 100MG 3

CRIXIVAN CAPS 200MG, 3 MO400MGdidanosine 2 MO

EDURANT 5 MO

EMTRIVA 3 MO

EPIVIR 3 MO

EPIVIR HBV 3 MO

EPZICOM 5 MO

famciclovir 2 MO

foscarnet sodium 2 PA MO

FUZEON 5 MO

ganciclovir caps 2 MO

HEPSERA 5 QL(90 per90 days)

MOINTELENCE 5 MO

INVIRASE CAPS 4 MO

INVIRASE TABS 5 MO

ISENTRESS 5 MO

KALETRA ORAL SOLN 5 MO

KALETRA TABS 200MG; 5 MO50MGKALETRA TABS 100MG; 3 MO25MGLEXIVA SUSP 3 MO

LEXIVA TABS 5 MO

NORVIR 3 MO

PREZISTA TABS 150MG 3

PREZISTA TABS 75MG 3 MO

PREZISTA TABS 400MG, 5 MO600MGREBETOL ORAL SOLN 3 PA MO

RELENZA DISKHALER 3 QL(300 per365 days)

MORESCRIPTOR 4 MO

RETROVIR IV INFUSION 3 MO

REYATAZ 3 MO

ribapak 5 PA MO

ribasphere caps 2 PA MO

ribasphere tabs 200mg 2 PA MO

2

Require-Drug Drug ments/Name Tier Limitsribasphere tabs 400mg 5 PA

ribasphere tabs 600mg 5 PA MO

ribavirin 2 PA

rimantadine hcl 2 MO

SELZENTRY 5 MO

stavudine 2 MO

SUSTIVA 3 MO

TAMIFLU CAPS 45MG, 75MG 3 QL(60 per365 days)

MOTAMIFLU CAPS 30MG 3 QL(120 per

365 days)MO

TAMIFLU SUSR 12MG/ML 3 MO

TRIZIVIR 5 MO

TRUVADA 5 MO

TYZEKA 5 MO

valacyclovir hcl tabs 1000mg 2 QL(100 per90 days)

MOvalacyclovir hcl tabs 500mg 2 QL(200 per

90 days)MO

VALCYTE ORAL SOLN 5

VALCYTE TABS 5 MO

VIDEX PEDIATRIC ORAL 3 MOSOLN 2GMVIRACEPT POWD 3 MO

VIRACEPT TABS 5 MO

VIRAMUNE 3 MO

VIREAD 3 MO

ZIAGEN 3 MO

zidovudine 2 MO

CEPHALOSPORINScefaclor 2 MO

cefadroxil 2 MO

cefazolin inj 1gm; 5%, 20gm, 2500mgcefazolin inj 1gm 2 MO

cefdinir 2 MO

cefepime inj 2gm 2

cefepime inj 1gm 2 MO

cefotaxime sodium inj 10gm, 1gm, 2500mg

Require-Drug Drug ments/Name Tier Limitscefotaxime sodium inj 2gm 2 MO

cefoxitin sodium inj 10gm, 2gm 2

cefoxitin sodium inj 1gm 2 MO

cefpodoxime proxetil 2 MO

ceftazidime inj 1gm, 6gm 2

ceftazidime inj 2gm 2 MO

ceftriaxone sodium inj 10gm 2

ceftriaxone sodium inj 1gm, 2 MO250mg, 2gm, 500mgcefuroxime axetil 2 MO

cefuroxime sodium inj 7.5gm 2

cefuroxime sodium inj 1.5gm, 2 MO750mgcephalexin 1 MO

FORTAZ INJ 1GM/50ML; 5%, 32GM/50ML; 5%, 6GMSUPRAX SUSR 4 MO

TAZICEF INJ 1GM, 2GM, 6GM 3

TEFLARO 3

ZINACEF IN ISO-OSMOTIC 3DEXTROSEZINACEF IN ISO-OSMOTIC 3DILUENTZINACEF INJ 1.5GM, 750MG 3

ERYTHROMYCINS / OTHERMACROLIDESazithromycin inj 500mg 2 MO

azithromycin susr 2 MO

azithromycin tabs 2 MO

clarithromycin 2 MO

clarithromycin er 2 MO

e.e.s. 400 2 MO

E.E.S. GRANULES 3 MO

ERY-TAB TBEC 500MG 3 MO

ery-tab tbec 250mg, 333mg 2 MO

ERYTHROCIN 3LACTOBIONATE INJ 500MGerythrocin stearate 1 MO

ERYTHROMYCIN BASE 3 MO

erythromycin ethylsuccinate 2 MO

erythromycin/sulfisoxazole 2 MO

ZMAX 3 MO

MISCELLANEOUS ANTIINFECTIVES

3

Require-Drug Drug ments/Name Tier LimitsALBENZA 3 MO

ALINIA 3 MO

amikacin sulfate inj 500mg/2ml 2

amikacin sulfate inj 50mg/ml 2 MO

AZACTAM IN ISO-OSMOTIC 3DEXTROSEAZACTAM INJ 2GM 3 MO

aztreonam inj 1gm 2 MO

BILTRICIDE 3 MO

CAPASTAT SULFATE 4

CAYSTON 5 LA

chloroquine 2 MO

CLEOCIN GALAXY 3

CLEOCIN PEDIATRIC 3 MOGRANULESclindamycin hcl 2 MO

clindamycin phosphate add- 2 MOvantageCOARTEM 3 MO

colistimethate sodium 2 MO

CUBICIN 3 PA MO

DAPSONE 3 MO

DARAPRIM 3 MO

ethambutol tabs 400mg 2

ethambutol tabs 100mg 2 MO

gentamicin sulfate inj 10mg/ml 2

gentamicin sulfate inj 40mg/ml 2 MO

gentamicin sulfate/0.9% sodium 2chloridegentamicin sulfate/sodium 2chloride inj 1.2mg/ml; 0.9%hydroxychloroquine 2 MO

isonarif 2 MO

ISONIAZID SYRP 3 MO

isoniazid tabs 1 MO

isotonic gentamicin inj 0.6mg/ml; 20.9%, 0.8mg/ml; 0.9%KETEK 3 QL(20 per

30 days)MO

MALARONE 3 MO

mebendazole 2 MO

mefloquine hcl 2 MO

Require-Drug Drug ments/Name Tier LimitsMEPRON 5 MO

meropenem inj 500mg 2 MO

metronidazole 1 MO

metronidazole in nacl 0.79% 2 MO

MYCOBUTIN 3 MO

NEBUPENT 3 PA MO

neomycin sulfate 2 MO

paromomycin 2 MO

PASER 3 MO

PRIMAQUINE 3 MO

PRIMAXIN I.M. 3 MO

PRIMAXIN IV 3 MO

pyrazinamide 2 MO

QUALAQUIN 3 MO

rifampin 2 MO

SEROMYCIN 3 MO

STREPTOMYCIN SULFATE 3 MO

STROMECTOL 3 MO

TOBI 5 PA MO

tobramycin inj 10mg/ml 1

tobramycin inj 80mg/2ml 1 MO

TOBRAMYCIN SULFATE / 3SODIUM CHLORIDETRECATOR 3 MO

TYGACIL 3 MO

XIFAXAN TABS 200MG 3 QL(9 per 30days) MO

XIFAXAN TABS 550MG 3 QL(180 per90 days)

MOZYVOX INJ 3 MO

ZYVOX SUSR 3 QL(1800per 30 days)

MOZYVOX TABS 3 QL(56 per

30 days)MO

PENICILLINSamoxicillin 1 MO

amoxicillin/clavulanate potassium 2 MO

amoxicillin/clavulanate potassium 2 MOer

4

Require-Drug Drug ments/Name Tier Limitsamoxicillin/potassium clavulanate 2 MOtabsampicillin caps 2 MO

ampicillin inj 10gm, 1gm 2

AMPICILLIN INJ 125MG 3

ampicillin susr 2 MO

ampicillin-sulbactam inj 10gm; 25gmampicillin-sulbactam inj 2gm; 2 MO1gmBICILLIN C-R 3 MO

BICILLIN L-A 3 MO

dicloxacillin sodium 2 MO

nafcillin sodium inj 10gm 2

nafcillin sodium inj 1gm 2 MO

NALLPEN/DEXTROSE INJ 0; 31GM/50MLPENICILLIN G POTASSIUM IN 3ISO-OSMOTIC DEXTROSEpenicillin g potassium inj 5mu 2

PENICILLIN G PROCAINE 3 MO

PENICILLIN G SODIUM 3

penicillin v potassium 1 MO

pfizerpen-g inj 20mu 2

piperacillin sodium/tazobactam 2 MOsodium inj 3gm; 0.375gmZOSYN INJ 5%; 2GM/50ML; 30.25GM/50ML, 5%; 3GM/50ML;0.375GM/50ML

QUINOLONESAVELOX ABC PACK 3 MO

AVELOX INJ 3

AVELOX TABS 3 MO

CIPRO I.V.-IN D5W INJ 3 MO200MG; 5%ciprofloxacin inj 400mg/40ml 1

ciprofloxacin tabs 1 MO

LEVAQUIN INJ 5%; 4750MG/150MLLEVAQUIN INJ 25MG/ML 4 MO

LEVAQUIN ORAL SOLN 4 MO

LEVAQUIN TABS 4 MO

NOROXIN 4 MO

ofloxacin 2 MO

Require-Drug Drug ments/Name Tier Limits

SULFA'S / RELATED AGENTSsulfadiazine 2 MO

sulfamethoxazole/trimethoprim 1 MO

sulfamethoxazole/trimethoprim ds 1 MO

TETRACYCLINESdemeclocycline hcl 2 MO

doxycycline hyclate caps 1 MO

doxycycline hyclate inj 1 MO

doxycycline hyclate tabs 1 MO

doxycycline hyclate tbec 1 MO

doxycycline monohydrate tabs 2 MO150mg, 50mg, 75mgminocycline hcl 2 MO

minocycline hcl er 2 MO

tetracycline hcl 1 MO

VIBRAMYCIN SYRP 3 MO

URINARY TRACT AGENTSMACRODANTIN CAPS 25MG 3 MO

methenamine hippurate 2 MO

nitrofurantoin 2 MO

nitrofurantoin macrocrystalline 2 MOcaps 50mgnitrofurantoin monohydrate 2 MO

PRIMSOL 4 MO

trimethoprim 2 MO

VANCOMYCINVANCOCIN ORAL 3 MO

vancomycin inj 10gm, 500mg 2 PA

vancomycin inj 1000mg 2 PA MO

VIBATIV INJ 250MG 3

ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSADJUNCTIVE AGENTSamifostine 5 MO

dexrazoxane inj 500mg 2 MO

ELITEK INJ 1.5MG 5

leucovorin calcium inj 100mg, 2 MO350mgleucovorin calcium tabs 25mg, 2 MO5mgLEUCOVORIN CALCIUM 3 MOTABS 10MG, 15MG

5

Require-Drug Drug ments/Name Tier Limitsmesna 2 MO

MESNEX TABS 3 MO

XGEVA 5 PA QL(5.1per 90 days)

MOZINECARD INJ 250MG 3 MO

ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSABRAXANE 4 MO

adriamycin inj 2mg/ml 2

AFINITOR TABS 10MG 5 PA QL(180per 90 days)

MOAFINITOR TABS 2.5MG, 5MG 5 PA QL(270

per 90 days)MO

ALIMTA INJ 500MG 4 MO

ALKERAN INJ 4

anastrozole 2 MO

ARRANON 4

ARZERRA 3 MO

AVASTIN INJ 100MG/4ML 4 MO

azathioprine 2 PA MO

azathioprine sodium 2 PA MO

bicalutamide 2 MO

BICNU 4 MO

bleomycin sulfate inj 30unit 2 MO

BUSULFEX 3

CAMPATH 4

carboplatin inj 150mg/15ml 2 MO

CEENU 3 MO

CELLCEPT INTRAVENOUS 3

CELLCEPT SUSR 3 PA MO

cisplatin inj 100mg/100ml 2 MO

cladribine 2 MO

CLOLAR 4

COSMEGEN 4 MO

cyclophosphamide tabs 2 PA MO

cyclosporine caps 100mg, 25mg 2 PA MO

CYCLOSPORINE CAPS 50MG 3 PA

cyclosporine inj 2 PA

cyclosporine oral soln 2 PA MO

Require-Drug Drug ments/Name Tier LimitsCYTARABINE AQUEOUS INJ 3 MO100MG/MLcytarabine aqueous inj 20mg/ml 2 MO

cytarabine inj 500mg 2 MO

dacarbazine inj 200mg 2 MO

DACOGEN 3 MO

daunorubicin hcl inj 20mg 2

DAUNOXOME 4 MO

DOCETAXEL INJ 80MG/8ML 3

DOXIL 3 MO

doxorubicin hcl 2

DROXIA 3 MO

ELLENCE INJ 200MG/100ML 4 MO

ELOXATIN INJ 100MG/20ML 4 MO

ELSPAR 4 MO

EMCYT 3 MO

epirubicin hcl inj 50mg/25ml 2

ERBITUX INJ 100MG/50ML 4 MO

ETOPOPHOS 4 MO

etoposide inj 2 MO

exemestane 2 MO

FARESTON 4 MO

FASLODEX 5 MO

FIRMAGON INJ 120MG 5 QL(1 per 90days) MO

FIRMAGON INJ 80MG 3 MO

fludarabine phosphate inj 50mg 2 MO

fluorouracil inj 500mg/10ml 2 MO

flutamide 2 MO

gemcitabine hcl inj 1gm 5 MO

gengraf 2 PA MO

GLEEVEC 5 MO

HALAVEN 5 MO

HERCEPTIN 4 MO

HEXALEN 5 MO

hydroxyurea 2 MO

idarubicin hcl inj 10mg/10ml 2

IFEX INJ 3GM 4 MO

ifosfamide inj 1gm 2

ifosfamide/mesna 5

irinotecan inj 100mg/5ml 5 MO

ISTODAX 3 MO

6

Require-Drug Drug ments/Name Tier LimitsIXEMPRA KIT INJ 45MG 5 MO

JEVTANA 5 MO

letrozole 2 MO

LEUKERAN 3 MO

leuprolide acetate 2 MO

LUPRON DEPOT INJ 3.75MG 3 MO

LUPRON DEPOT INJ 11.25MG, 5 MO22.5MG, 30MG, 7.5MGLUPRON DEPOT-PED INJ 5 MO11.25MG, 15MGLYSODREN 3 MO

MATULANE 5 MO

MEGACE ES 3 QL(150 per30 days)

MOmegestrol acetate susp 1 QL(600 per

30 days)MO

megestrol acetate tabs 1 QL(240 per30 days)

MOmelphalan hydrochloride 2

mercaptopurine 2 MO

methotrexate 2 PA MO

methotrexate sodium inj 25mg/ml 2 MO

METHOTREXATE SODIUM 4INJ 1GMmitomycin inj 20mg 2 MO

mitoxantrone hcl 2 MO

MUSTARGEN 4 MO

mycophenolate mofetil 2 PA MO

MYFORTIC 3 PA MO

NEORAL 3 PA MO

NEXAVAR 5 LA PAQL(360 per

90 days)MO

NILANDRON 4 QL(120 per90 days)

MONIPENT 4 MO

octreotide inj 100mcg/ml, 2 MO200mcg/ml, 50mcg/mloctreotide inj 1000mcg/ml, 5 MO500mcg/ml

Require-Drug Drug ments/Name Tier LimitsONTAK 4

oxaliplatin inj 100mg/20ml 5

paclitaxel inj 300mg/50ml 2 MO

pentostatin 2 MO

PHOTOFRIN 4

PROGRAF INJ 3 PA

RAPAMUNE 3 PA MO

REVLIMID CAPS 15MG, 25MG 5 LA QL(21per 28 days)

MOREVLIMID CAPS 10MG, 5MG 5 LA QL(30

per 30 days)MO

RHEUMATREX 4 PA MO

RITUXAN 3 PA MO

SANDIMMUNE CAPS 3 PA MO

SANDIMMUNE INJ 3 PA

SANDIMMUNE ORAL SOLN 3 PA MO

SANDOSTATIN LAR DEPOT 4 MO

SIMULECT INJ 20MG 3 MO

SOMATULINE DEPOT 5 MO

SPRYCEL TABS 100MG, 5 QL(90 per140MG, 50MG, 70MG, 80MG 90 days)

MOSPRYCEL TABS 20MG 5 QL(180 per

90 days)MO

SUTENT 5 PA QL(90per 90 days)

MOTABLOID 3 MO

tacrolimus 2 PA MO

tamoxifen citrate 2 MO

TARCEVA TABS 100MG, 5 PA QL(90150MG per 90 days)

MOTARCEVA TABS 25MG 5 PA QL(180

per 90 days)MO

TARGRETIN 3 MO

TASIGNA CAPS 200MG 5 QL(336 per84 days)

MOTAXOTERE INJ 80MG/2ML 5

7

Require-Drug Drug ments/Name Tier LimitsTAXOTERE INJ 80MG/4ML 5 MO

THALOMID 5 PA MO

thiotepa 2 MO

toposar 2 MO

topotecan hcl inj 4mg 2 MO

TORISEL 5 PA MO

TREANDA INJ 100MG 5 MO

TRELSTAR DEPOT MIXJECT 4 MO

TRELSTAR LA MIXJECT 4 MO

TRELSTAR MIXJECT 4

tretinoin 2 MO

TRISENOX 3 MO

TYKERB 5 LA QL(540per 90 days)

MOVANDETANIB TABS 300MG 5 QL(90 per

90 days)VANDETANIB TABS 100MG 5 QL(180 per

90 days)VECTIBIX INJ 100MG/5ML 5 MO

VELCADE 4 MO

VIDAZA 5 QL(4200per 90 days)

MOvinblastine sulfate inj 10mg 2

vincasar pfs 2 MO

vincristine sulfate 2 MO

vinorelbine tartrate inj 50mg/5ml 2 MO

VOTRIENT 5 QL(360 per90 days)

MOZANOSAR 4 MO

ZOLINZA 5 QL(360 per90 days)

MOZORTRESS TABS 0.5MG, 5 PA MO0.75MGZORTRESS TABS 0.25MG 3 PA MO

ZYTIGA 5 PA QL(360per 90 days)

MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCHANTICONVULSANTS

Require-Drug Drug ments/Name Tier LimitsBANZEL 3 MO

carbamazepine 1 MO

carbamazepine er tb12 1 MO

CARBATROL 3 MO

CELONTIN 3 MO

DILANTIN CAPS 30MG 3 MO

DILANTIN INFATABS 3 MO

divalproex sodium cpsp 2 MO

divalproex sodium er 2 MO

divalproex sodium tbec 2 MO

epitol 1 MO

EQUETRO 3 MO

ethosuximide 2 MO

FELBATOL 3 MO

gabapentin 2 MO

GABITRIL 3 MO

LAMICTAL ODT TBDP 3 MO

LAMICTAL XR KIT 3 MO

LAMICTAL XR TB24 100MG, 3 MO200MG, 25MG, 50MGlamotrigine 2 MO

levetiracetam inj 2

levetiracetam oral soln 2 MO

levetiracetam tabs 2 MO

LYRICA CAPS 225MG, 300MG 3 QL(180 per90 days)

MOLYRICA CAPS 100MG, 150MG, 3 QL(270 per200MG, 25MG, 50MG, 75MG 90 days)

MOoxcarbazepine 2 MO

PEGANONE 3 MO

phenytoin 2 MO

PHENYTOIN SODIUM 3

phenytoin sodium extended 2 MO

primidone 2 MO

SABRIL 3 MO

TEGRETOL-XR TB12 100MG 3 MO

topiramate 2 MO

valproate sodium 2 MO

valproic acid 2 MO

VIMPAT INJ 3

8

Require-Drug Drug ments/Name Tier LimitsVIMPAT ORAL SOLN 3 MO

VIMPAT TABS 3 MO

zonisamide 2 MO

ANTIPARKINSONISM AGENTSAPOKYN 3 LA MO

AZILECT 3 MO

benztropine mesylate inj 1

benztropine mesylate tabs 1 MO

bromocriptine mesylate 2 MO

carbidopa / levodopa 2 MO

carbidopa/levodopa cr 2 MO

carbidopa/levodopa odt 2 MO

carbidopa/levodopa sr tbcr 50mg; 2 MO200mgCOMTAN 3 MO

LODOSYN 3 MO

MIRAPEX ER TB24 0.375MG, 3 MO0.75MG, 1.5MG, 3MG, 4.5MGpramipexole dihydrochloride 2 MO

REQUIP XL 3 MO

ropinirole 2 MO

selegiline 2 MO

STALEVO 100 3 MO

STALEVO 125 3 MO

STALEVO 150 3 MO

STALEVO 200 3 MO

STALEVO 50 3 MO

STALEVO 75 3 MO

trihexyphenidyl 1 MO

ZELAPAR 3 MO

MIGRAINE / CLUSTER HEADACHETHERAPYdihydroergotamine mesylate 2 MO

ergotamine tartrate / caffeine 2 MO

MAXALT 3 QL(36 per90 days)

MOMAXALT-MLT 3 QL(36 per

90 days)MO

migergot 2 MO

Require-Drug Drug ments/Name Tier LimitsMIGRANAL 4 QL(24 per

90 days)MO

naratriptan hcl tabs 2.5mg 2 QL(24 per90 days)

MOnaratriptan hcl tabs 1mg 2 QL(36 per

90 days)MO

RELPAX 3 QL(24 per90 days)

MOsumatriptan succinate inj 2 QL(12 per6mg/0.5ml 90 days)

MOsumatriptan succinate tabs 100mg 2 QL(27 per

90 days)MO

sumatriptan succinate tabs 25mg, 2 QL(54 per50mg 90 days)

MO

MISCELLANEOUS NEUROLOGICALTHERAPYARICEPT ODT 3 QL(90 per

90 days)MO

ARICEPT TABS 23MG 3 QL(90 per90 days)

MOCOPAXONE 5 PA QL(90

per 90 days)MO

donepezil hcl 2 QL(90 per90 days)

MOEXELON ORAL SOLN 3 MO

EXELON PT24 3 QL(90 per90 days)

MOgalantamine hydrobromide cp24 2 QL(90 per

90 days)MO

galantamine hydrobromide oral 2 MOsolngalantamine hydrobromide tabs 2 QL(180 per

90 days)MO

9

Require-Drug Drug ments/Name Tier LimitsGILENYA 5 PA QL(28

per 28 days)MO

MYTELASE 3 MO

NAMENDA ORAL SOLN 3 MO

NAMENDA TABS 10MG 3 QL(180 per90 days)

MONAMENDA TABS 5MG 3 QL(270 per

90 days)MO

NAMENDA TITRATION PAK 3 MO

NUEDEXTA 3 QL(180 per90 days)

MOrivastigmine tartrate 2 QL(180 per

90 days)MO

XENAZINE 5 LA MO

MUSCLE RELAXANTS /ANTISPASMODIC THERAPYbaclofen 1 MO

cyclobenzaprine hcl 1 MO

dantrolene sodium caps 2 MO

MESTINON SYRP 3 MO

MESTINON TIMESPAN 3 MO

pyridostigmine bromide 2 MO

regonol 2

tizanidine hcl 2 MO

NARCOTIC ANALGESICSacetaminophen / codeine oral 2 MOsolnacetaminophen / codeine tabs 2 MO300mg; 15mgacetaminophen/codeine #3 2 MO

acetaminophen/codeine #4 2 MO

ascomp/codeine 2 MO

BUPRENEX 3 MO

buprenorphine hcl inj 2

buprenorphine hcl subl 2 MO

codeine sulfate 2 MO

DILAUDID INJ 3 MO

DILAUDID-5 3 MO

DILAUDID-HP INJ 10MG/ML 3

Require-Drug Drug ments/Name Tier Limitsduramorph 2 MO

EMBEDA 4

endocet 2 MO

EXALGO 4 MO

fentanyl citrate 2

fentanyl citrate oral transmucosal 2 PA QL(360lpop 200mcg per 90 days)

MOfentanyl citrate oral transmucosal 5 PA QL(360lpop 1200mcg, 1600mcg, 400mcg, per 90 days)600mcg, 800mcg MOfentanyl patches 2 MO

hydrocodone 2 MObitartrate/acetaminophen tabshydrocodone/acetaminophen oral 2 MOsoln 500mg/15ml; 7.5mg/15mlhydrocodone/acetaminophen tabs 2 MO

hydrocodone/ibuprofen 2 MO

hydromorphone hcl inj 10mg/ml 2 MO

hydromorphone hcl tabs 2 MO

INFUMORPH 200 3 MO

INFUMORPH 500 3 MO

KADIAN 3 MO

levorphanol tartrate 2 MO

margesic-h 2 MO

methadone hcl conc 2 MO

methadone hcl inj 2

methadone hcl oral soln 5mg/5ml 2 MO

METHADONE HCL ORAL 3 MOSOLN 10MG/5MLmethadone hcl tabs 2 MO

methadose tabs 2 MO

morphine sulfate er 2 MO

morphine sulfate inj 0.5mg/ml 2

morphine sulfate inj 1mg/ml 2 MO

morphine sulfate oral soln 2 MO

morphine sulfate tabs 2 MO

ONSOLIS FILM 1200MCG, 3 QL(360 per400MCG, 600MCG, 800MCG 90 days)ONSOLIS FILM 200MCG 3 QL(720 per

90 days)OPANA ER 3 MO

oxycodone / acetaminophen caps 2 MO

10

Require-Drug Drug ments/Name Tier Limitsoxycodone / acetaminophen tabs 2325mg; 5mgoxycodone / acetaminophen tabs 2 MO325mg; 10mg, 325mg; 2.5mg,325mg; 7.5mg, 500mg; 7.5mg,650mg; 10mgoxycodone hcl caps 2 MO

oxycodone hcl conc 2 MO

oxycodone hcl tabs 15mg, 30mg, 2 MO5mgoxycodone/aspirin tabs 325mg; 24.835mgoxycodone/aspirin tabs 325mg; 2 MO4.5mg; 0.38mgOXYCONTIN 3 MO

oxymorphone hydrochloride 2 MO

reprexain tabs 10mg; 200mg 2 MO

ROXICET ORAL SOLN 3 MO

roxicet tabs 325mg; 5mg 2 MO

stagesic 2 MO

zerlor 2 MO

NON-NARCOTIC ANALGESICSARTHROTEC 50 4 MO

ARTHROTEC 75 4 MO

butorphanol tartrate nasal soln 2 PA QL(30per 90 days)

MOCELEBREX 3 QL(180 per

90 days)MO

depade 2 MO

diclofenac potassium 2 MO

diclofenac sodium 1 MO

diclofenac sodium ec 1 MO

diclofenac sodium xr 1 MO

diflunisal 2 MO

etodolac 2 MO

fenoprofen calcium 2 MO

FLECTOR 4 MO

flurbiprofen 2 MO

ibuprofen susp 1 MO

ibuprofen tabs 400mg, 600mg, 1 MO800mgindomethacin caps 1 MO

Require-Drug Drug ments/Name Tier Limitsindomethacin er 1 MO

ketoprofen 2 MO

ketoprofen er 2 MO

meclofenamate sodium 2 MO

mefenamic acid 2 MO

meloxicam 1 MO

nabumetone 2 MO

naloxone 2

naltrexone 2 MO

naproxen sodium tabs 275mg, 2 MO550mgnaproxen susp 1 MO

naproxen tabs 250mg, 375mg 1 MO

naproxen tbec 1 MO

oxaprozin 2 MO

PENNSAID 3 MO

piroxicam 1 MO

SUBOXONE 3 MO

sulindac 2 MO

tolmetin sodium 2 MO

tramadol 2 QL(720 per90 days)

MOtramadol hcl er 2 QL(90 per

90 days)MO

VIMOVO 3 QL(180 per90 days)

MOVOLTAREN GEL 3 MO

PSYCHOTHERAPEUTIC DRUGSABILIFY DISCMELT TBDP 3 QL(180 per15MG 90 days)

MOABILIFY DISCMELT TBDP 3 QL(270 per10MG 90 days)

MOABILIFY INJ 3 MO

ABILIFY ORAL SOLN 3 MO

ABILIFY TABS 20MG, 2MG, 3 QL(90 per30MG, 5MG 90 days)

MO

11

Require-Drug Drug ments/Name Tier LimitsABILIFY TABS 15MG 3 QL(180 per

90 days)MO

ABILIFY TABS 10MG 3 QL(270 per90 days)

MOamitriptyline 1 MO

amoxapine 2 MO

budeprion sr 2 QL(180 per90 days)

MObudeprion xl tb24 300mg 2 QL(90 per

90 days)MO

budeprion xl tb24 150mg 2 QL(270 per90 days)

MObupropion hcl 2 MO

bupropion hcl sr 2 QL(180 per90 days)

MObuspirone hcl 2 MO

chlordiazepoxide/amitriptyline 2 MO

chlorpromazine 2 MO

citalopram oral soln 1 MO

citalopram tabs 40mg 1 QL(90 per90 days)

MOcitalopram tabs 10mg 1 QL(180 per

90 days)MO

citalopram tabs 20mg 1 QL(270 per90 days)

MOclomipramine 2 MO

clozapine tabs 100mg, 25mg, 250mgCLOZAPINE TABS 200MG 3

CYMBALTA CPEP 60MG 3 QL(90 per90 days)

MOCYMBALTA CPEP 20MG, 3 QL(180 per30MG 90 days)

MOdesipramine 2 MO

dextroamphetamine sulfate 2 PA MO

Require-Drug Drug ments/Name Tier Limitsdextroamphetamine sulfate er 2 PA MO

doxepin 1 MO

EMSAM 4 QL(90 per90 days)

MOFANAPT TABS 1MG, 2MG, 4 QL(90 per4MG 90 days)

MOFANAPT TABS 10MG, 12MG, 4 QL(180 per6MG, 8MG 90 days)

MOFANAPT TITRATION PACK 4 MO

FAZACLO 4

fluoxetine caps 40mg 1 QL(180 per90 days)

MOfluoxetine caps 20mg 1 QL(360 per

90 days)MO

fluoxetine caps 10mg 1 QL(720 per90 days)

MOfluoxetine dr 1 QL(12 per

90 days)MO

fluoxetine oral soln 1 MO

fluoxetine tabs 20mg 1 QL(360 per90 days)

MOfluoxetine tabs 10mg 1 QL(720 per

90 days)MO

fluphenazine conc 1

fluphenazine decanoate inj 1 MO

fluphenazine elix 1 MO

fluphenazine inj 1 MO

fluphenazine tabs 1 MO

fluvoxamine 2 QL(270 per90 days)

MOFOCALIN XR 3 PA MO

GEODON CAPS 3 QL(180 per90 days)

MOGEODON INJ 3 MO

HALDOL 3 MO

12

Require-Drug Drug ments/Name Tier LimitsHALDOL DECANOATE 100 3 MO

HALDOL DECANOATE 50 3 MO

haloperidol conc 2 MO

haloperidol decanoate inj 2 MO

haloperidol lactate inj 2 MO

haloperidol tabs 1 MO

imipramine 2 MO

imipramine pamoate 2 MO

INVEGA SUSTENNA INJ 3 QL(0.75 per39MG/0.25ML 90 days)

MOINVEGA SUSTENNA INJ 3 QL(1.5 per78MG/0.5ML 90 days)

MOINVEGA SUSTENNA INJ 3 QL(2.25 per117MG/0.75ML 90 days)

MOINVEGA SUSTENNA INJ 3 QL(3 per 90156MG/ML days) MOINVEGA SUSTENNA INJ 3 QL(4.5 per234MG/1.5ML 90 days)

MOINVEGA TB24 1.5MG, 3MG, 3 QL(90 per9MG 90 days)

MOINVEGA TB24 6MG 3 QL(180 per

90 days)MO

LATUDA TABS 80MG 3 QL(90 per90 days)

MOLATUDA TABS 40MG 3 QL(180 per

90 days)MO

LEXAPRO ORAL SOLN 3 MO

LEXAPRO TABS 3 QL(90 per90 days)

MOlithium carbonate 1 MO

lithium carbonate er 1 MO

lithium citrate 2 MO

loxapine 2 MO

maprotiline 2 MO

MARPLAN 3 MO

Require-Drug Drug ments/Name Tier LimitsMETADATE CD CPCR 20MG, 4 PA MO30MG, 40MG, 50MG, 60MGmethylphenidate hcl tabs 20mg 2 PA

methylphenidate hcl tabs 10mg, 2 PA MO5mgmethylphenidate hydrochloride 2 PA MO

mirtazapine 2 QL(90 per90 days)

MOmirtazapine odt tbdp 30mg, 45mg 2 QL(90 per

90 days)MO

nefazodone 2 QL(180 per90 days)

MOnortriptyline 1 MO

ORAP 3 MO

paroxetine er tb24 12.5mg, 1 QL(180 per37.5mg 90 days)

MOparoxetine er tb24 25mg 1 QL(270 per

90 days)MO

paroxetine susp 1 MO

paroxetine tabs 20mg, 40mg 1 QL(90 per90 days)

MOparoxetine tabs 10mg, 30mg 1 QL(180 per

90 days)MO

PAXIL SUSP 3 MO

perphenazine 2 MO

phenelzine sulfate 2 MO

PRISTIQ 3 QL(90 per90 days)

MOprotriptyline hcl 2 MO

PROVIGIL 3 PA QL(90per 90 days)

MORISPERDAL CONSTA 3 QL(12 per

84 days)MO

risperidone odt 2 QL(180 per90 days)

MO

13

Require-Drug Drug ments/Name Tier Limitsrisperidone oral soln 2 MO

risperidone tabs 2 QL(180 per90 days)

MORITALIN LA 4 PA MO

ROZEREM 4 MO

SAPHRIS 3 QL(180 per90 days)

MOSEROQUEL TABS 25MG, 3 QL(180 per300MG, 400MG 90 days)

MOSEROQUEL TABS 100MG, 3 QL(270 per200MG, 50MG 90 days)

MOSEROQUEL XR TB24 150MG, 3 QL(180 per300MG, 400MG 90 days)

MOSEROQUEL XR TB24 200MG, 3 QL(270 per50MG 90 days)

MOsertraline conc 2 MO

sertraline tabs 100mg, 25mg 2 QL(180 per90 days)

MOsertraline tabs 50mg 2 QL(270 per

90 days)MO

SILENOR 4 QL(90 per90 days)

MOSTRATTERA 3 MO

SURMONTIL 4 MO

SYMBYAX 4 QL(90 per90 days)

MOthioridazine 2 MO

thiothixene 1 MO

tranylcypromine 2 MO

trazodone 1 MO

trifluoperazine 2 MO

venlafaxine hcl er cp24 150mg, 2 QL(90 per37.5mg 90 days)

MO

Require-Drug Drug ments/Name Tier Limitsvenlafaxine hcl er cp24 75mg 2 QL(270 per

90 days)MO

venlafaxine hcl tabs 100mg, 2 QL(270 per25mg, 37.5mg 90 days)

MOvenlafaxine hcl tabs 75mg 2 QL(450 per

90 days)MO

venlafaxine hcl tabs 50mg 2 QL(675 per90 days)

MOVIIBRYD 4 PA QL(90

per 90 days)MO

XYREM 5 PA

zaleplon caps 5mg 2 QL(90 per90 days)

MOzaleplon caps 10mg 2 QL(180 per

90 days)MO

zolpidem 2 MO

zolpidem tartrate er 2 MO

ZYPREXA INJ 3 MO

ZYPREXA TABS 3 QL(90 per90 days)

MOZYPREXA ZYDIS 3 QL(90 per

90 days)MO

CARDIOVASCULAR,HYPERTENSION / LIPIDSANTIARRHYTHMIC AGENTSamiodarone inj 50mg/ml 2

amiodarone tabs 2 MO

disopyramide phosphate 2 MO

flecainide acetate 2 MO

mexiletine 2 MO

MULTAQ 3 MO

NORPACE CR CP12 100MG 3 MO

PACERONE TABS 100MG 3 MO

pacerone tabs 200mg 2 MO

procainamide 2

14

Require-Drug Drug ments/Name Tier Limitspropafenone hcl 2 MO

propafenone hcl er 2 MO

quinidine gluconate er 2 MO

quinidine sulfate 2 MO

quinidine sulfate er 2 MO

sorine tabs 240mg 1

sorine tabs 120mg, 160mg, 80mg 1 MO

sotalol 1 MO

TIKOSYN 4 MO

ANTIHYPERTENSIVE THERAPYacebutolol 2 MO

afeditab cr 2 MO

amiloride 2 MO

amiloride/hydrochlorothiazide 1 MO

amlodipine 2 MO

amlodipine / benazepril 2 QL(90 per90 days)

MOAMTURNIDE 3 QL(90 per

90 days)MO

atenolol 1 MO

atenolol / chlorthalidone 1 MO

benazepril 1 MO

benazepril / hydrochlorothiazide 2 QL(360 pertabs 20mg; 12.5mg, 20mg; 25mg 90 days)

MObenazepril / hydrochlorothiazide 2 QL(720 pertabs 10mg; 12.5mg 90 days)

MObenazepril / hydrochlorothiazide 2 QL(1440tabs 5mg; 6.25mg per 90 days)

MObetaxolol hcl 2 MO

BIDIL 3 QL(540 per90 days)

MObisoprolol fumarate 2 MO

bisoprolol fumarate / 1 MOhydrochlorothiazidebumetanide 1 MO

BYSTOLIC 3 MO

captopril 1 MO

Require-Drug Drug ments/Name Tier Limitscaptopril/hydrochlorothiazide 2 QL(90 pertabs 25mg; 15mg, 25mg; 25mg, 90 days)50mg; 15mg MOcaptopril/hydrochlorothiazide 2 QL(270 pertabs 50mg; 25mg 90 days)

MOcartia xt 2 MO

carvedilol 2 MO

chlorothiazide 1 MO

chlorothiazide sodium 2 MO

chlorthalidone tabs 25mg, 50mg 1 MO

clonidine ptwk 2 MO

clonidine tabs 1 MO

COREG CR 3 MO

DEMSER 3 MO

DIBENZYLINE 4 MO

dilt-cd cp24 120mg, 300mg 2 MO

dilt-xr cp24 180mg, 240mg 2

diltiazem cd cp24 120mg, 240mg, 2 MO300mgdiltiazem hcl er cp12 2 MO

diltiazem hcl er cp24 360mg, 2 MO420mgdiltiazem hcl inj 25mg/5ml 2

DILTIAZEM HCL INJ 100MG 3

diltiazem hcl tabs 2 MO

diltzac cp24 120mg, 180mg, 2 MO240mg, 300mgDIOVAN HCT 3 QL(90 per

90 days)MO

DIOVAN TABS 320MG 3 QL(90 per90 days)

MODIOVAN TABS 160MG, 40MG, 3 QL(180 per80MG 90 days)

MOdoxazosin 1 QL(180 per

90 days)MO

EDECRIN 3 MO

enalapril 1 MO

enalapril / hydrochlorothiazide 1 QL(90 pertabs 5mg; 12.5mg 90 days)

MO

15

Require-Drug Drug ments/Name Tier Limitsenalapril / hydrochlorothiazide 1 QL(180 pertabs 10mg; 25mg 90 days)

MOeplerenone 2 MO

EXFORGE 3 QL(90 per90 days)

MOEXFORGE HCT 3 QL(90 per

90 days)MO

felodipine er 2 MO

fosinopril 2 MO

fosinopril / hydrochlorothiazide 2 QL(90 pertabs 10mg; 12.5mg 90 days)

MOfosinopril / hydrochlorothiazide 2 QL(360 pertabs 20mg; 12.5mg 90 days)

MOfurosemide inj 1 MO

furosemide oral soln 10mg/ml 1 MO

FUROSEMIDE ORAL SOLN 3 MO8MG/MLfurosemide tabs 1 MO

guanfacine hcl 1 MO

hydralazine 1 MO

hydrochlorothiazide 1 MO

indapamide 1 MO

isradipine 2 MO

labetalol inj 2

labetalol tabs 2 MO

lisinopril 1 MO

lisinopril/hydrochlorothiazide 1 QL(90 pertabs 12.5mg; 10mg, 12.5mg; 90 days)20mg MOlisinopril/hydrochlorothiazide 1 QL(360 pertabs 25mg; 20mg 90 days)

MOlosartan potassium tabs 100mg 2 QL(90 per

90 days)MO

losartan potassium tabs 25mg, 2 QL(180 per50mg 90 days)

MO

Require-Drug Drug ments/Name Tier Limitslosartan 2 QL(90 perpotassium/hydrochlorothiazide 90 days)tabs 12.5mg; 100mg, 25mg; MO100mglosartan 2 QL(180 perpotassium/hydrochlorothiazide 90 days)tabs 12.5mg; 50mg MOmatzim la 2 MO

methyclothiazide 2 MO

metolazone 2 MO

metoprolol succinate er 2

metoprolol tartrate inj 1

metoprolol tartrate tabs 1 MO

metoprolol/hydrochlorothiazide 2 MO

MICARDIS HCT 3 QL(90 per90 days)

MOMICARDIS TABS 20MG, 40MG 3 QL(90 per

90 days)MO

MICARDIS TABS 80MG 3 QL(180 per90 days)

MOminoxidil tabs 2 MO

moexipril 2 MO

moexipril/hydrochlorothiazide 2 QL(90 pertabs 12.5mg; 15mg, 12.5mg; 90 days)7.5mg MOmoexipril/hydrochlorothiazide 2 QL(180 pertabs 25mg; 15mg 90 days)

MOnadolol 1 MO

nadolol/bendroflumethiazide 2 MO

nicardipine caps 2 MO

nifediac cc 2 MO

nifedical xl 2 MO

nifedipine 2 MO

nifedipine er tb24 30mg, 60mg 2

nifedipine er tb24 90mg 2 MO

nimodipine 2 MO

nisoldipine 2 MO

nisoldipine er 2 MO

perindopril erbumine 2 MO

pindolol 1 MO

16

Require-Drug Drug ments/Name Tier Limitsprazosin 1 QL(360 per

90 days)MO

propranolol hcl er 1 MO

propranolol hcl inj 1

propranolol hcl oral soln 1 MO

propranolol hcl tabs 1 MO

propranolol/hydrochlorothiazide 2 MO

quinapril 2 MO

quinapril/hydrochlorothiazide 2 QL(90 per90 days)

MOramipril 2 MO

REMODULIN 5 PA MO

reserpine 2 MO

SODIUM EDECRIN 3

spironolactone 1 MO

spironolactone/hydrochlorothiazi 2 MOdetaztia xt 2 MO

TEKAMLO 3 QL(90 per90 days)

MOTEKTURNA 3 QL(90 per

90 days)MO

TEKTURNA HCT 3 QL(90 per90 days)

MOterazosin hcl 1 QL(180 per

90 days)MO

timolol maleate 1 MO

torsemide tabs 2 MO

trandolapril 2 MO

triamterene/hydrochlorothiazide 1 MO

TWYNSTA 3 QL(90 per90 days)

MOVALTURNA 3 QL(90 per

90 days)MO

verapamil er cp24 1 MO

verapamil er tbcr 120mg, 240mg 1

verapamil er tbcr 180mg 1 MO

Require-Drug Drug ments/Name Tier Limitsverapamil inj 1

verapamil tabs 1 MO

CARDIAC GLYCOSIDESdigoxin inj 1

digoxin oral soln 1 MO

digoxin tabs 1 MO

LANOXIN INJ 3

LANOXIN TABS 3 MO

COAGULATION THERAPYAGGRENOX 3 MO

ARIXTRA 3 MO

cilostazol 2 MO

CYKLOKAPRON 3 MO

EFFIENT 3 MO

enoxaparin sodium inj 2 MO30mg/0.3ml, 40mg/0.4ml,60mg/0.6ml, 80mg/0.8mlenoxaparin sodium inj 100mg/ml, 5 MO120mg/0.8ml, 150mg/mlFRAGMIN 3 MO

HEPARIN SODIUM INJ 3 MO2000UNIT/MLheparin sodium inj 10000unit/ml, 2 MO1000unit/ml, 20000unit/ml,5000unit/mlheparin sodium/d5w inj 5%; 240unit/mlHEPARIN SODIUM/NACL 30.45%heparin sodium/sodium chloride 20.9% premixjantoven 1 MO

LOVENOX INJ 300MG/3ML 3 MO

pentopak 2 MO

pentoxifylline er 2 MO

PLAVIX 3 MO

PRADAXA 3 MO

PROMACTA TABS 50MG, 5 LA PA75MG QL(90 per

90 days)MO

17

Require-Drug Drug ments/Name Tier LimitsPROMACTA TABS 25MG 5 LA PA

QL(270 per90 days)

MOticlopidine hcl 2 MO

warfarin 1 MO

LIPID/CHOLESTEROL LOWERINGAGENTSCADUET 3 QL(90 per

90 days)MO

cholestyramine light pack 2 MO

colestipol 2 MO

CRESTOR 3 QL(90 per90 days)

MOfenofibrate 2 MO

fenofibrate micronized 2 MO

gemfibrozil 2 MO

lipitor 2 QL(90 per90 days)

MOlovastatin tabs 10mg 1 QL(90 per

90 days)MO

lovastatin tabs 20mg, 40mg 1 QL(180 per90 days)

MOLOVAZA 3 MO

NIASPAN 3 MO

pravastatin tabs 10mg, 20mg, 2 QL(90 per80mg 90 days)

MOpravastatin tabs 40mg 2 QL(180 per

90 days)MO

prevalite powd 2 MO

simvastatin 2 QL(90 per90 days)

MOTRICOR 3 MO

TRILIPIX 3 MO

WELCHOL 3 MO

Require-Drug Drug ments/Name Tier LimitsZETIA 3 QL(90 per

90 days)MO

MISCELLANEOUS CARDIOVASCULARAGENTSRANEXA 3 MO

NITRATESisosorbide dinitrate 1 MO

isosorbide dinitrate er 1 MO

isosorbide mononitrate 2 MO

isosorbide mononitrate er 1 MO

nitro-bid 2 MO

NITRO-DUR PT24 0.3MG/HR, 3 MO0.8MG/HRnitroglycerin inj 2 PA

nitroglycerin pt24 0.2mg/hr, 20.6mg/hrnitroglycerin pt24 0.4mg/hr 2 MO

nitroglycerin transdermal pt24 2 MO0.1mg/hrNITROLINGUAL PUMPSPRAY 3 MO

NITROSTAT 3 MO

DERMATOLOGICALS/TOPICALTHERAPYANTIPSORIATIC / ANTISEBORRHEICcalcipotriene 2 MO

selenium sulfide lotn 2.5% 1 MO

SORIATANE 3 MO

BURN THERAPYsilver sulfadiazine 2 MO

ssd 2 MO

thermazene 2 MO

MISCELLANEOUS DERMATOLOGICALS8-MOP 3 MO

ammonium lactate 2 MO

CARAC 3 MO

CARMOL-HC 3 MO

CONDYLOX GEL 3 MO

ELIDEL 4 MO

FLUOROPLEX 3 MO

fluorouracil crea 2 MO

fluorouracil external soln 2 MO

18

Require-Drug Drug ments/Name Tier Limitsimiquimod 2 MO

laclotion 2 MO

OXSORALEN ULTRA 5 MO

PANRETIN 3 MO

podofilox 2 MO

PROTOPIC 4 MO

REGRANEX 3 PA MO

SOLARAZE 3 MO

UVADEX 4

VEREGEN 4 MO

ZONALON 3 MO

THERAPY FOR ACNEadapalene 2

amnesteem 2

avita crea 2 MO

AZELEX 3 MO

claravis caps 10mg, 20mg, 40mg 2

claravis caps 30mg 5

clindamycin phosphate external 2 MOsolnclindamycin phosphate foam 2 MO

clindamycin phosphate gel 2 MO

clindamycin phosphate lotn 2 MO

clindamycin phosphate swab 2 MO

clindamycin/benzoyl peroxide 2 MO

DIFFERIN LOTN 3 MO

ery 1 MO

erythromycin / benzoyl peroxide 2 MO

erythromycin external soln 1 MO

erythromycin gel 1 MO

FINACEA 3 MO

METROGEL 3 MO

metronidazole 1 MO

sotret 2

TAZORAC 3 MO

tretinoin 2 MO

TOPICAL ANESTHETICSlidocaine / prilocaine crea 2 MO

lidocaine external soln 2 MO

lidocaine gel 2 MO

lidocaine inj 0.5%, 1% 2

Require-Drug Drug ments/Name Tier Limitslidocaine oint 2 MO

lidocaine viscous 2 MO

LIDODERM 3 PA MO

TOPICAL ANTIBACTERIALSALTABAX 3 MO

BACTROBAN CREA 3 MO

gentamicin sulfate crea 1 MO

gentamicin sulfate oint 0.1% 1 MO

mupirocin 2 MO

PHISOHEX 3 MO

sodium sulfacetamide 2 MO

SULFAMYLON 3 MO

TOPICAL ANTIFUNGALSciclopirox 2 MO

ciclopirox nail lacquer 2 MO

ciclopirox olamine 2 MO

clotrimazole / betamethasone 2 MO

clotrimazole external crea 2 MO

clotrimazole external soln 2 MO

econazole nitrate 2 MO

ketoconazole 2 MO

NAFTIN 3 MO

nyamyc 1 MO

nystatin / triamcinolone 1 MO

nystatin crea 1 MO

nystatin external powd 1

nystatin oint 1 MO

nystop 1 MO

pedi-dri 1 MO

TOPICAL ANTIVIRALSDENAVIR 3 MO

ZOVIRAX CREA 4 MO

ZOVIRAX OINT 4 MO

TOPICAL CORTICOSTEROIDSala cort 1 MO

alclometasone dipropionate 2 MO

amcinonide crea 2 MO

amcinonide lotn 2 MO

amcinonide oint 2

augmented betamethasone 1 MOdipropionate crea

19

Require-Drug Drug ments/Name Tier Limitsaugmented betamethasone 2 MOdipropionate lotnaugmented betamethasone 1 MOdipropionate ointbetamethasone dipropionate 2 MO

betamethasone valerate 1 MO

CAPEX 3 MO

clobetasol propionate e 2 MO

clobetasol propionate external 2solnclobetasol propionate gel 2 MO

clobetasol propionate oint 2 MO

CLOBEX LOTN 3 MO

CLOBEX SHAM 3 MO

CORDRAN TAPE 3 MO

DERMA-SMOOTHE / FS BODY 3 MOOILdesonide 2 MO

desoximetasone 2 MO

diflorasone diacetate 2 MO

fluocinolone acetonide 1 MO

fluocinonide emollient base 2

fluocinonide external soln 2 MO

fluocinonide gel 2 MO

fluocinonide oint 2 MO

fluticasone propionate 2 MO

halobetasol propionate 2 MO

hydrocortisone butyrate 2 MO

hydrocortisone crea 1%, 2.5% 1 MO

hydrocortisone lotn 2.5% 1 MO

hydrocortisone oint 1%, 2.5% 1 MO

hydrocortisone valerate 2 MO

LOCOID LOTN 3 MO

LUXIQ 3 MO

mometasone furoate 2 MO

PANDEL 3 MO

prednicarbate 2 MO

triamcinolone acetonide crea 1 MO

triamcinolone acetonide lotn 1 MO

triamcinolone acetonide oint 1 MO

triderm 1 MO

TOPICAL ENZYMES

Require-Drug Drug ments/Name Tier LimitsSANTYL 3 MO

TOPICAL SCABICIDES / PEDICULICIDESacticin 2 MO

EURAX 3 MO

LINDANE 3 QL(1800per 365

days) MOmalathion 2 MO

permethrin crea 2 MO

ULESFIA 4 MO

DIAGNOSTICS / MISCELLANEOUSAGENTSMISCELLANEOUS AGENTSACTONEL TABS 30MG 4 PA QL(60

per 120days) MO

ADAGEN 5 LA MO

alendronate sodium tabs 40mg 2 PA QL(180per 365

days) MOanagrelide hydrochloride 2 MO

ANTABUSE TABS 250MG 3 MO

ARALAST NP INJ 400MG 5 LA MO

BUPHENYL 3 MO

CAMPRAL 3 QL(540 per90 days)

MOCHEMET 3 MO

CLINIMIX / DEXTROSE 3

DEXTROSE 10%/NACL 0.45% 3

dextrose 10% flex container 2

DEXTROSE 10%/NACL 0.2% 3

dextrose 2.5%/sodium chloride 20.45%dextrose 5% 2 MO

dextrose 5%/nacl 0.2% 2

dextrose 5%/nacl 0.225% 2

DEXTROSE 5%/NACL 0.33% 3

dextrose 5%/nacl 0.45% 2 MO

dextrose 5%/nacl 0.9% 2 MO

etidronate disodium 2 MO

EVOXAC 4 MO

EXJADE TBSO 125MG 3 LA MO

20

Require-Drug Drug ments/Name Tier LimitsEXJADE TBSO 250MG, 500MG 5 LA MO

FOSRENOL 3 MO

INCRELEX 5 LA PA MO

kionex powd 2 MO

levocarnitine oral soln 2 PA MO

levocarnitine tabs 2 PA MO

midodrine 2 MO

ORFADIN 5 LA MO

pilocarpine hcl tabs 2 MO

PROLASTIN INJ 500MG 5 LA MO

PROLASTIN-C 5 LA

RENAGEL 3 MO

RENVELA 3 MO

RILUTEK 5 MO

SKELID 4 PA QL(180per 90 days)

MOsodium chloride 0.9% 2 MO

sodium chloride inj 0.9% 2 MO

sodium polystyrene sulfonate 2 MO

SYPRINE 3 MO

SMOKING DETERRENTSbuproban 2 PA QL(180

per 90 days)MO

CHANTIX TABS 3 PA MO

CHANTIX TABS 0.5MG, 1MG 3 PA QL(168per 90 days)

MONICOTROL INHALER 4 PA

QL(1008per 90 days)

MONICOTROL NASAL 4 PA QL(120

per 90 days)MO

EAR, NOSE / THROATMEDICATIONSMISCELLANEOUS AGENTSASTEPRO 3 MO

azelastine hcl 2 MO

BACTROBAN NASAL 3 MO

Require-Drug Drug ments/Name Tier Limitschlorhexidine gluconate oral 1 MOrinseipratropium bromide nasal soln 1 MO

periogard 1 MO

triamcinolone in orabase 1 MO

TYZINE 3 MO

TYZINE PEDIATRIC NASAL 3DROPS

MISCELLANEOUS OTICPREPARATIONSacetasol hc 2 MO

acetic acid 2 MO

acetic acid / hydrocortisone 2 MO

DERMOTIC 3 MO

ofloxacin 2 MO

OTIC STEROID / ANTIBIOTICCIPRO HC 4 MO

CIPRODEX 3 MO

COLY-MYCIN S 3 MO

CORTISPORIN-TC 3 MO

cortomycin 2 MO

neomycin/polymyxin/hc 2 MO

neomycin/polymyxin/hydrocortiso 2 MOne otic susp

ENDOCRINE/DIABETESADRENAL HORMONESa-hydrocort 2 MO

a-methapred inj 40mg 2 PA

a-methapred inj 125mg 2 PA MO

cortisone acetate 2 MO

DEPO-MEDROL 3 PA MO

dexamethasone elix 1 MO

dexamethasone inj 4mg/ml 1 MO

DEXAMETHASONE 3 MOINTENSOLdexamethasone tabs 0.5mg, 1 MO0.75mg, 1.5mg, 4mg, 6mgDEXAMETHASONE TABS 3 MO1MG, 2MGfludrocortisone acetate 2 MO

hydrocortisone tabs 1 MO

methylprednisolone acetate 2 PA MO

21

Require-Drug Drug ments/Name Tier Limitsmethylprednisolone 2 PAsodiumsuccinate inj 125mg, 40mgMETHYLPREDNISOLONE 3 PA MOSODIUMSUCCINATE INJ1000MGmethylprednisolone tabs 32mg 1 PA

methylprednisolone tabs 16mg, 1 PA MO4mg, 8mgprednisolone sodium phosphate 2 PA MOoral solnprednisone 1 PA MO

PREDNISONE INTENSOL 3 PA MO

SOLU-CORTEF INJ 100MG, 3 MO250MGSOLU-MEDROL INJ 2GM 3 PA

SOLU-MEDROL INJ 125MG, 3 PA MO40MG, 500MG

ANTITHYROID AGENTSmethimazole 2 MO

propylthiouracil 2 MO

DIABETES THERAPYacarbose 2 QL(270 per

90 days)MO

ACTOPLUS MET 3 QL(270 per90 days)

MOACTOS 3 QL(90 per

90 days)MO

ALCOHOL PREPS 3

AVANDAMET 3 QL(180 per90 days)

MOAVANDARYL TABS 2MG; 3 QL(90 per8MG, 4MG; 4MG, 4MG; 8MG 90 days)

MOAVANDARYL TABS 1MG; 3 QL(180 per4MG, 2MG; 4MG 90 days)

MOAVANDIA TABS 8MG 3 QL(90 per

90 days)MO

AVANDIA TABS 2MG, 4MG 3 QL(180 per90 days)

MO

Require-Drug Drug ments/Name Tier LimitsBD INSULIN SYRINGE 3 MOSAFETYGLIDE/1ML/29G X1/2"BD INSULIN SYRINGE 3 MOULTRAFINE/0.3ML/31G X5/16"BD INSULIN SYRINGE 3 MOULTRAFINE/0.5ML/30G X 1/2"BD INSULIN SYRINGE 3 MOULTRAFINE/1ML/31G X 5/16"BD PEN 3 MONEEDLE/ULTRAFINE/29G X12.7MMBYETTA 4 QL(7.2 per

90 days) STMO

DUETACT 3 QL(90 per90 days)

MOGAUZE PADS 2"X2" 3 MO

glimepiride tabs 1mg, 2mg 1 QL(90 per90 days)

MOglimepiride tabs 4mg 1 QL(180 per

90 days)MO

glipizide / metformin 2 QL(360 per90 days)

MOglipizide er tb24 2.5mg, 5mg 1 QL(90 per

90 days)glipizide er tb24 10mg 1 QL(180 per

90 days)glipizide tabs 10mg 1 QL(360 per

90 days)MO

glipizide tabs 5mg 1 QL(720 per90 days)

MOGLUCAGEN HYPOKIT 3 MO

GLUCAGON EMERGENCY 3 MOKITglyburide / metformin tabs 2 QL(180 per1.25mg; 250mg, 2.5mg; 500mg 90 days)

MO

22

Require-Drug Drug ments/Name Tier Limitsglyburide / metformin tabs 5mg; 2 QL(360 per500mg 90 days)

MOglyburide micronized 1 QL(180 per

90 days)MO

glyburide tabs 1.25mg, 2.5mg 1 QL(180 per90 days)

MOglyburide tabs 5mg 1 QL(360 per

90 days)MO

glycron tabs 1.5mg 1 QL(180 per90 days)

MOGLYCRON TABS 4.5MG 3 QL(360 per

90 days)HUMALOG 3 QL(60 per

30 days)MO

HUMALOG KWIKPEN 3 QL(60 per30 days)

MOHUMALOG MIX 50/50 3 QL(60 per

30 days)MO

HUMALOG MIX 50/50 3 QL(60 perKWIKPEN 30 days)

MOHUMALOG MIX 75/25 3 QL(60 per

30 days)MO

HUMALOG MIX 75/25 3 QL(60 perKWIKPEN 30 days)

MOHUMULIN 70/30 3 QL(60 per

30 days)MO

HUMULIN 70/30 PEN 3 QL(60 per30 days)

MOHUMULIN N 3 QL(60 per

30 days)MO

HUMULIN N U-100 PEN 3 QL(60 per30 days)

MO

Require-Drug Drug ments/Name Tier LimitsHUMULIN R 3 QL(60 per

30 days)MO

HUMULIN R U-500 3 QL(60 per(CONCENTRATED) 30 days)

MOJANUMET 3 QL(180 per

90 days)MO

JANUVIA 3 QL(90 per90 days)

MOKOMBIGLYZE XR TB24 3 QL(90 per1000MG; 5MG, 500MG; 5MG 90 days)

MOKOMBIGLYZE XR TB24 3 QL(180 per1000MG; 2.5MG 90 days)

MOLANTUS 3 QL(30 per

30 days)MO

LANTUS SOLOSTAR 3 QL(30 per30 days)

MOmetformin hcl er tb24 750mg 1 QL(270 per

90 days)MO

metformin hcl er tb24 500mg 1 QL(450 per90 days)

MOmetformin hcl tabs 1000mg 1 QL(180 per

90 days)MO

metformin hcl tabs 850mg 1 QL(270 per90 days)

MOmetformin hcl tabs 500mg 1 QL(450 per

90 days)MO

nateglinide 2 QL(270 per90 days)

MONOVOLOG 3 QL(60 per

30 days)MO

NOVOLOG FLEXPEN 3 QL(60 per30 days)

MO

23

Require-Drug Drug ments/Name Tier LimitsNOVOLOG MIX 70/30 3 QL(60 per

30 days)MO

NOVOLOG MIX 70/30 3 QL(60 perPREFILLED FLEXPEN 30 days)

MOONGLYZA 3 QL(90 per

90 days)MO

PRANDIN TABS 0.5MG, 1MG 3 QL(360 per90 days)

MOPRANDIN TABS 2MG 3 QL(720 per

90 days)MO

PROGLYCEM 3 MO

SYMLIN 4 QL(60 per90 days)

SYMLINPEN 120 4 QL(33 per90 days)

MOSYMLINPEN 60 4 QL(33 per

90 days)MO

tolazamide 2 MO

tolbutamide 2 MO

MISCELLANEOUS HORMONESALDURAZYME 5 LA PA MO

ANADROL-50 4 PA MO

ANDRODERM 3 PA MO

ANDROGEL GEL 50MG/5GM 3 PA MO

ANDROGEL PUMP GEL 1.62% 3 PA MO

ANDROID 3 PA MO

androxy 2 PA MO

cabergoline 2 MO

calcitonin-salmon 2 QL(12 per90 days)

MOcalcitriol 2 PA MO

CEREZYME INJ 200UNIT 5 LA PA MO

danazol 2 MO

desmopressin acetate 2 MO

FABRAZYME INJ 35MG 5 LA PA MO

Require-Drug Drug ments/Name Tier Limitsfortical 2 QL(12 per

90 days)MO

KUVAN 5 LA MO

NAGLAZYME 5 LA MO

oxandrolone tabs 10mg 5 PA MO

oxandrolone tabs 2.5mg 2 PA MO

SAMSCA TABS 30MG 5 QL(730 per365 days)

MOSAMSCA TABS 15MG 5 QL(1460

per 365days) MO

SENSIPAR TABS 60MG, 90MG 5 MO

SENSIPAR TABS 30MG 3 MO

SOMAVERT 3 PA QL(90per 90 days)

MOSTIMATE 3 MO

SYNAREL 4 MO

testosterone cypionate inj 2 PA MO100mg/mltestosterone enanthate 2 PA MO

ZAVESCA 3 LA

ZEMPLAR 3 PA MO

ZOMETA 5 QL(30 per90 days)

MO

THYROID HORMONESlevothyroxine tabs 1

levoxyl 1 MO

liothyronine sodium tabs 2 MO

SYNTHROID 3 MO

unithroid tabs 100mcg, 112mcg, 1 MO125mcg, 150mcg, 175mcg,200mcg, 25mcg, 300mcg, 50mcg,75mcg, 88mcg

GASTROENTEROLOGYANTIDIARRHEALS / ANTISPASMODICSatropine sulfate inj 0.1mg/ml 2

ATROPINE SULFATE INJ 30.05MG/MLdicyclomine hcl caps 2 MO

dicyclomine hcl inj 2

24

Require-Drug Drug ments/Name Tier Limitsdicyclomine hcl oral soln 2 MO

dicyclomine hcl tabs 2 MO

glycopyrrolate 2 MO

loperamide hcl caps 2 MO

propantheline bromide 2 MO

MISCELLANEOUS GASTROINTESTINALAGENTSAMITIZA 3 MO

ASACOL 3 MO

ASACOL HD 3 MO

balsalazide 2 MO

CANASA 3 MO

CIMZIA 5 PA QL(6per 28 days)

MOcompro 2 MO

constulose 1 MO

CORTIFOAM 3 MO

CREON CPEP 120000UNIT; 3 MO24000UNIT; 76000UNIT,30000UNIT; 6000UNIT;19000UNIT, 60000UNIT;12000UNIT; 38000UNITCYSTADANE 3 MO

DIPENTUM 4 MO

dronabinol 2 PA MO

EMEND CAPS 40MG 3 PA QL(3per 90 days)

MOEMEND CAPS 125MG 3 PA QL(6

per 90 days)MO

EMEND CAPS 3 PA QL(18per 90 days)

MOEMEND CAPS 80MG 3 PA QL(24

per 90 days)MO

ENTOCORT EC 3 MO

enulose 1 MO

GASTROCROM 3 MO

gavilyte-c 2 QL(4000per 30 days)

MO

Require-Drug Drug ments/Name Tier Limitsgavilyte-g 2 QL(4000

per 30 days)MO

gavilyte-n/flavor pack 2 QL(4000per 30 days)

MOgranisetron inj 0.1mg/ml, 1mg/ml 2 QL(42 per

90 days)MO

granisetron tabs 2 PA QL(180per 90 days)

MOhydrocortisone enem 1

lactulose 1 MO

LOTRONEX 3 QL(180 per90 days)

MOmeclizine hcl 2 MO

mesalamine enem 2 MO

metoclopramide 1 MO

ondansetron hcl inj 4mg/2ml 2 MO

ondansetron hcl oral soln 2 PA MO

ondansetron hcl tabs 24mg 2 PA QL(21per 90 days)

ondansetron hcl tabs 4mg, 8mg 2 PA QL(135per 90 days)

MOondansetron odt 2 PA QL(135

per 90 days)MO

PENTASA 3 MO

polyethylene glycol 3350 powd 2 MO

prochlorperazine 2

prochlorperazine edisylate 2 MO

prochlorperazine maleate 1 MO

procto-pak 1 MO

proctosol hc 1 MO

proctozone-hc 1 MO

RELISTOR 3 MO

REMICADE 5 PA MO

SANCUSO 3 QL(6 per 90days) MO

sulfasalazine tabs 2 MO

sulfazine ec 2

TRANSDERM-SCOP 4 MO

25

Require-Drug Drug ments/Name Tier Limitstrilyte 2 QL(4000

per 30 days)MO

ursodiol caps 2 MO

ursodiol tabs 2

ZENPEP 3 MO

ZUPLENZ 3 PA QL(135per 90 days)

MO

ULCER THERAPYCARAFATE SUSP 3 MO

DEXILANT 4 QL(90 per90 days) ST

MOfamotidine inj 1 MO

famotidine premixed 2

famotidine susr 1 MO

famotidine tabs 20mg, 40mg 1 MO

lansoprazole 2 QL(180 per90 days)

MOlansoprazole odt 2 QL(180 per

90 days)MO

misoprostol 2 MO

NEXIUM 3 QL(90 per90 days)

MONEXIUM I.V. INJ 20MG 3

NEXIUM I.V. INJ 40MG 3 MO

nizatidine 2 MO

omeprazole cpdr 40mg 2 QL(90 per90 days)

MOomeprazole cpdr 10mg, 20mg 2 QL(180 per

90 days)MO

omeprazole/sodium bicarbonate 2 QL(90 per90 days)

MOPREVPAC 4 MO

PYLERA 3 MO

ranitidine hcl caps 1 MO

ranitidine hcl syrp 1 MO

ranitidine hcl tabs 1 MO

Require-Drug Drug ments/Name Tier Limitssucralfate 2 MO

ZANTAC INJ 50MG/50ML; 3 MO0.45%

IMMUNOLOGY, VACCINES /BIOTECHNOLOGYBIOTECHNOLOGY DRUGSACTIMMUNE 5 LA PA MO

ARANESP INJ 500MCG/ML 3 PA QL(3per 90 days)

MOARANESP INJ 150MCG/0.3ML 3 PA QL(3.6

per 90 days)MO

ARANESP INJ 200MCG/0.4ML 3 PA QL(4.8per 90 days)

MOARANESP INJ 100MCG/0.5ML 3 PA QL(6

per 90 days)MO

ARANESP INJ 300MCG/0.6ML, 3 PA QL(7.260MCG/0.3ML per 90 days)

MOARANESP INJ 40MCG/0.4ML 3 PA QL(9.6

per 90 days)MO

ARANESP INJ 25MCG/0.42ML 3 PAQL(10.08

per 90 days)MO

ARANESP INJ 100MCG/ML, 3 PA QL(12200MCG/ML, 300MCG/ML per 90 days)

MOARANESP INJ 25MCG/ML, 3 PA QL(2440MCG/ML, 60MCG/ML per 90 days)

MOARCALYST 5 LA MO

AVONEX 5 PA QL(12per 90 days)

MOBETASERON 5 PA QL(45

per 90 days)MO

EPOGEN INJ 20000UNIT/ML, 4 PA QL(362000UNIT/ML, 3000UNIT/ML, per 90 days)4000UNIT/ML MO

26

Require-Drug Drug ments/Name Tier LimitsEPOGEN INJ 10000UNIT/ML 4 PA QL(72

per 90 days)MO

INTRON-A INJ 3MU/0.2ML 3 PA

INTRON-A INJ 3 PA MO6000000UNIT/MLINTRON-A INJ 10MU/0.2ML, 5 PA5MU/0.2MLINTRON-A WITH DILUENT 5 PA MOINJ 10MULEUKINE 5 PA MO

MOZOBIL 5 QL(4.8 per90 days)

MONEULASTA 4 PA QL(3.6

per 90 days)MO

NEUMEGA 5 PA QL(63per 90 days)

MONEUPOGEN INJ 5 PA QL(21300MCG/0.5ML per 90 days)

MONEUPOGEN INJ 5 PA QL(33.6480MCG/0.8ML per 90 days)

MONEUPOGEN INJ 5 PA QL(67.2480MCG/1.6ML per 90 days)

MONORDITROPIN FLEXPRO 5 PA MO

NORDITROPIN NORDIFLEX 5 PA MOPENomnitrope inj 5mg/1.5ml 2 PA MO

PEG-INTRON INJ 5 PA QL(1250MCG/0.5ML per 90 days)

MOPEG-INTRON REDIPEN 5 PA QL(12

per 90 days)MO

PEGASYS INJ 180MCG/0.5ML 5 PA QL(6per 90 days)

MOPEGASYS INJ 180MCG/ML 5 PA QL(12

per 90 days)MO

Require-Drug Drug ments/Name Tier LimitsPROCRIT INJ 40000UNIT/ML 3 PA QL(18

per 90 days)MO

PROCRIT INJ 10000UNIT/ML, 3 PA QL(3620000UNIT/ML, 2000UNIT/ML, per 90 days)3000UNIT/ML, 4000UNIT/ML MOPROLEUKIN 5 MO

REBIF 5 PA QL(18per 90 days)

MOREBIF TITRATION PACK 5 PA MO

TEV-TROPIN 3 PA MO

VACCINES / MISCELLANEOUSIMMUNOLOGICALSACTHIB 3

ADACEL 3 MO

BOOSTRIX 3 MO

CERVARIX 3 PA

COMVAX 3 MO

DAPTACEL 3 MO

DECAVAC 3 MO

DIPHTHERIA/TETANUS 3 MOTOXOID PEDIATRICENGERIX-B INJ 10MCG/0.5ML 3 PA

ENGERIX-B INJ 20MCG/ML 3 PA MO

GARDASIL 3 PA MO

HAVRIX INJ 720ELU/0.5ML 3

HAVRIX INJ 1440ELU/ML 3 MO

HIZENTRA INJ 1GM/5ML 5 PA MO

IMOVAX RABIES (H.D.C.V.) 3

INFANRIX 3 MO

IPOL INACTIVATED IPV 3 MO

IXIARO 3

JE-VAX 3 MO

M-M-R II W/DILUENT 10 3 MODOSEMENACTRA 3

MENOMUNE-A/C/Y/W-135 3 MO

MENVEO 3

PEDVAX HIB 3 MO

PRIVIGEN INJ 20GM/200ML 5 PA MO

PROQUAD 3

RABAVERT 3 MO

27

Require-Drug Drug ments/Name Tier LimitsRECOMBIVAX HB INJ 3 PA40MCG/MLRECOMBIVAX HB INJ 3 PA MO10MCG/MLROTATEQ 3

TETANUS / DIPHTHERIA 3 MOTOXOIDS-ADSORBED ADULTTETANUS TOXOID 3ADSORBEDTHYMOGLOBULIN 3 PA

TRIPEDIA 3

TWINRIX 3 PA MO

TYPHIM VI 3

VAQTA 3 MO

VARIVAX 3

VIVAGLOBIN 5 PA MO

YF-VAX 3

ZOSTAVAX 3 PA

MUSCULOSKELETAL /RHEUMATOLOGYGOUT THERAPYallopurinol 1 MO

COLCRYS 3 QL(360 per90 days)

MOprobenecid 2 MO

probenecid / colchicine 2 MO

ULORIC 3 MO

OSTEOPOROSIS THERAPYACTONEL TABS 150MG 4 QL(3 per 90

days) STMO

ACTONEL TABS 35MG 4 QL(12 per90 days) ST

MOACTONEL TABS 5MG 4 QL(90 per

90 days) STMO

alendronate sodium tabs 35mg, 2 QL(12 per70mg 90 days)

MOalendronate sodium tabs 10mg, 2 QL(90 per5mg 90 days)

MO

Require-Drug Drug ments/Name Tier LimitsBONIVA TABS 4 PA MO

EVISTA 3 QL(90 per90 days)

MOFORTEO 3 QL(7.2 per

90 days)MO

OTHER RHEUMATOLOGICALSCUPRIMINE 3 MO

DEPEN TITRATABS 3 MO

ENBREL 5 PA QL(600per 90 days)

MOHUMIRA INJ 20MG/0.4ML 5 PA QL(2.4

per 90 days)MO

HUMIRA INJ 40MG/0.8ML 5 PA QL(4.8per 90 days)

MOHUMIRA PEN-CROHNS 5 PA MODISEASE STARTERleflunomide 2 QL(90 per

90 days)MO

RIDAURA 4 MO

SAVELLA 3 QL(180 per90 days)

MOSAVELLA TITRATION PACK 3 MO

SIMPONI 5 PA QL(1per 30 days)

MO

OBSTETRICS / GYNECOLOGYESTROGENS / PROGESTINSALORA 3 MO

camila 2 MO

CLIMARA PRO 3 MO

COMBIPATCH 3 MO

CRINONE GEL 4% 3 MO

CRINONE GEL 8% 3 PA MO

DEPO-PROVERA 3 MO

DEPO-SUBQ PROVERA 104 4 MO

DIVIGEL GEL 1MG/GM 3 MO

errin 2 MO

28

Require-Drug Drug ments/Name Tier LimitsESTRADERM 3 MO

estradiol / norethindrone acetate 2 MOtabs 1mg; 0.5mgestradiol ptwk 1

estradiol tabs 1 MO

ESTRING 4 QL(1 per 90days) MO

estropipate 1 MO

jinteli 2 MO

jolivette 2 MO

medroxyprogesterone acetate 1 MO

MENOSTAR 4 MO

nora-be 2 MO

norethindrone tabs 5mg 2 MO

ortho-est 1

PREFEST 4 MO

PREMARIN TABS 3 MO

PREMARIN W/APPLICATOR 3 MO

PREMPHASE 3 MO

PREMPRO 3 MO

PROMETRIUM 3 MO

VAGIFEM 3 MO

VIVELLE-DOT 3 MO

MISCELLANEOUS OB/GYNCLEOCIN SUPP 3 MO

clindamycin phosphate crea 2 MO

GYNAZOLE-1 3

LYSTEDA 4 QL(120 per90 days)

MOmetronidazole vaginal 1 MO

miconazole 3 2 MO

NUVARING 4 MO

ORTHO EVRA 4 MO

terconazole 2 MO

vandazole 1 MO

zazole crea 0.4% 2 MO

ORAL CONTRACEPTIVES / RELATEDAGENTSapri 2 MO

aranelle 2 MO

aviane 2 MO

Require-Drug Drug ments/Name Tier Limitsbalziva 2 MO

cesia 2 MO

cryselle-28 2 MO

cyclafem 1/35 2 MO

cyclafem 7/7/7 2 MO

ELLA 3

enpresse-28 2 MO

gianvi 2 MO

junel 2 MO

junel fe 1.5/30 2 MO

junel fe 1/20 2 MO

kariva 2 MO

kelnor 1/35 2 MO

leena 2 MO

lessina-28 2 MO

levora 2 MO

low-ogestrel 2 MO

lutera 2 MO

microgestin 1.5/30 2 MO

microgestin 1/20 2 MO

microgestin fe 2 MO

microgestin fe 1.5/30 2 MO

mononessa 2 MO

necon 0.5/35-28 2 MO

necon 1/35-28 2 MO

necon 10/11-28 2 MO

necon 7/7/7 2 MO

next choice 2

nortrel 0.5/35 (28) 2 MO

nortrel 1/35 (21) 2 MO

nortrel 1/35 (28) 2 MO

nortrel 7/7/7 2 MO

ocella 2 MO

ogestrel 2 MO

portia-28 2 MO

previfem 2 MO

quasense 2 MO

reclipsen 2 MO

solia 2 MO

sprintec 28 2 MO

sronyx 2 MO

29

Require-Drug Drug ments/Name Tier Limitstri-legest fe 2 MO

tri-previfem 2 MO

tri-sprintec 2 MO

trinessa 2 MO

trivora-28 2 MO

velivet 2 MO

zeosa 2 MO

zovia 1/35e 2 MO

zovia 1/50e 2 MO

OXYTOCICSMETHERGINE TABS 3

OPHTHALMOLOGYANTIBIOTICSak-tob 1

AZASITE 3 MO

bacitracin / polymyxin b 2 MO

bacitracin ophthalmic oint 1 MO

BESIVANCE 3 MO

CILOXAN OINT 3 MO

ciprofloxacin ophthalmic soln 1 MO

erythromycin oint 1 MO

gentak 1 MO

gentamicin sulfate ophthalmic 1 MOsolngentasol 1 MO

levofloxacin ophthalmic soln 2 MO

MOXEZA 3 MO

NATACYN 3 MO

neomycin/bacitracin/polymyxin 1 MO

neomycin/polymyxin/gramicidin 2 MO

ofloxacin 2 MO

romycin 2 MO

tobramycin ophthalmic soln 1 MO

tobrasol 1

TOBREX OINT 3 MO

trimethoprim sulfate/polymyxin b 1 MOsulfateVIGAMOX 3 MO

ZYMAR 3 MO

ZYMAXID 3 MO

ANTIVIRALS

Require-Drug Drug ments/Name Tier Limitstrifluridine 2 MO

ZIRGAN 4 MO

BETA-BLOCKERSbetaxolol hcl 2 MO

BETOPTIC-S 3 MO

carteolol hcl 2 MO

ISTALOL 3 MO

levobunolol hcl 1 MO

metipranolol 2 MO

timolol maleate 1 MO

timolol maleate ophthalmic gel 1 MOformingTIMOPTIC OCUDOSE 3 MO

CYCLOPLEGIC MYDRIATICStropicamide 1 MO

DIRECT ACTING MIOTICSPILOPINE HS 3 MO

MISCELLANEOUS OPHTHALMOLOGICSALOCRIL 4 MO

azelastine hcl 2 MO

BEPREVE 3 MO

cromolyn sodium ophthalmic soln 2 MO

epinastine hcl 2 MO

LACRISERT 3 MO

PATADAY 3 MO

PATANOL 3 MO

RESTASIS 3 MO

NON-STEROIDAL ANTI-INFLAMMATORY AGENTSACUVAIL 3 MO

BROMDAY 3 MO

bromfenac 2 MO

diclofenac sodium 1 MO

flurbiprofen sodium 2 MO

ketorolac tromethamine 2 MOophthalmic solnNEVANAC 3 MO

ORAL DRUGS FOR GLAUCOMAacetazolamide 2 MO

acetazolamide sodium 2

methazolamide 2 MO

30

Require-Drug Drug ments/Name Tier Limits

OTHER GLAUCOMA DRUGSAZOPT 3 MO

COMBIGAN 3 MO

dorzolamide hcl 2 MO

dorzolamide hcl/timolol maleate 2 MO

latanoprost 2 MO

LUMIGAN 3 MO

TRAVATAN Z 3 MO

STEROID-ANTIBIOTIC COMBINATIONSneomycin/polymyxin/bacitracin/h 1 MOydrocortisoneneomycin/polymyxin/dexamethaso 1 MOneneomycin/polymyxin/hydrocortiso 2 MOne ophthalmic susppoly-dex oint 1 MO

poly-dex susp 1

TOBRADEX OINT 3 MO

TOBRADEX ST 3 MO

tobramycin/dexamethasone 2 MO

ZYLET 3 MO

STEROID-SULFONAMIDECOMBINATIONSsulfacetamide sodium / 2 MOprednisolone sodium phospha

STEROIDSALREX 3 MO

dexamethasone ophthalmic soln 1 MO

DUREZOL 3 MO

fluorometholone 2 MO

FML 3 MO

FML FORTE 3 MO

LOTEMAX 3 MO

prednisolone acetate 2 MO

prednisolone sodium phosphate 2 MOophthalmic soln

SULFONAMIDESBLEPH-10 3 MO

sodium sulfacetamide 2 MO

SYMPATHOMIMETICSALPHAGAN P 3 MO

apraclonidine 2 MO

Require-Drug Drug ments/Name Tier Limitsbrimonidine tartrate ophthalmic 2 MOsoln 0.2%IOPIDINE OPHTHALMIC 4 MOSOLN 1%

VASOCONSTRICTOR DECONGESTANTSak-con 1 MO

RESPIRATORY AND ALLERGYANTIHISTAMINE / ANTIALLERGENICAGENTScarbinoxamine maleate 2 MO

cetirizine hcl syrp 2 MO

CLARINEX REDITABS 3 QL(90 per90 days)

MOCLARINEX SYRP 3 MO

CLARINEX TABS 3 QL(90 per90 days)

MOCLARINEX-D 12 HOUR 3 QL(180 per

90 days)MO

CLARINEX-D 24 HOUR 3 QL(90 per90 days)

MOclemastine fumarate syrp 2 MO

clemastine fumarate tabs 2.68mg 2 MO

epinephrine hcl inj 0.1mg/ml 2

EPIPEN 3 MO

EPIPEN-JR 3 MO

fexofenadine hcl tabs 180mg 2 QL(90 per90 days)

fexofenadine hcl tabs 30mg, 60mg 2 QL(180 per90 days)

hydroxyzine hcl inj 25mg/ml 2

hydroxyzine hcl inj 50mg/ml 2 MO

hydroxyzine hcl syrp 2 MO

hydroxyzine hcl tabs 2 MO

levocetirizine dihydrochloride 2 QL(90 per90 days)

MOpalgic liqd 2 MO

phenadoz 2

promethazine hcl inj 25mg/ml 2

promethazine hcl inj 50mg/ml 2 MO

31

Require-Drug Drug ments/Name Tier Limitspromethazine hcl supp 2 MO

promethazine hcl syrp 2 MO

promethazine hcl tabs 2 MO

promethegan supp 25mg 2

promethegan supp 50mg 2 MO

TWINJECT 3 MO

PULMONARY AGENTSacetylcysteine 2 PA MO

ADVAIR DISKUS 3 QL(180 per90 days)

MOADVAIR HFA 3 QL(36 per

90 days)MO

albuterol sulfate er 1 MO

albuterol sulfate nebu 1 PA MO

albuterol sulfate syrp 1 MO

albuterol sulfate tabs 1 MO

aminophylline inj 1

aminophylline tabs 1 MO

ASMANEX 120 METERED 3 QL(3 per 90DOSES days) MOASMANEX 14 METERED 3 QL(3 per 90DOSES days) MOASMANEX 30 METERED 3 QL(3 per 90DOSES days) MOASMANEX 60 METERED 3 QL(3 per 90DOSES days) MOATROVENT HFA 3 QL(77.4 per

90 days)MO

budesonide susp 2 PA MO

COMBIVENT 3 QL(88.2 per90 days)

MOcromolyn sodium nebu 2 PA MO

DULERA 4 QL(39 per90 days)

MOELIXOPHYLLIN 4 MO

FLOVENT DISKUS 3 QL(360 per90 days)

MO

Require-Drug Drug ments/Name Tier LimitsFLOVENT HFA AERO 3 QL(63.6 per110MCG/ACT 90 days)

MOFLOVENT HFA AERO 3 QL(72 per220MCG/ACT, 44MCG/ACT 90 days)

MOflunisolide nasal soln 0.025% 2 MO

fluticasone propionate 2 MO

FORADIL AEROLIZER 3 QL(180 per90 days)

MOipratropium bromide inhalation 1 PA MOsolnipratropium bromide/albuterol 2 PA MOsulfateLETAIRIS 5 LA PA

QL(90 per90 days)

MOmetaproterenol sulfate 2 MO

NASONEX 3 MO

PERFOROMIST 3 PA MO

PROAIR HFA 3 QL(51 per90 days)

MOPULMICORT SUSP 1MG/2ML 3 PA MO

PULMOZYME 5 PA MO

REVATIO INJ 5 QL(3375per 90 days)

MOREVATIO TABS 5 PA QL(270

per 90 days)MO

SEREVENT DISKUS 3 QL(180 per90 days)

MOSINGULAIR 3 QL(90 per

90 days)MO

SPIRIVA HANDIHALER 3 QL(90 per90 days)

MOSYMBICORT AERO 3 QL(30.6 per80MCG/ACT; 4.5MCG/ACT 90 days)SYMBICORT AERO 3 QL(30.6 per160MCG/ACT; 4.5MCG/ACT 90 days)

MO

32

Require-Drug Drug ments/Name Tier Limitsterbutaline sulfate 2 MO

THEO-24 4 MO

theochron tb12 300mg 2

theochron tb12 100mg 2 MO

theophylline er 2 MO

TRACLEER 5 LA PAQL(180 per

90 days)MO

VENTOLIN HFA 3 QL(108 per90 days)

MOVERAMYST 3 MO

XOLAIR 5 PA QL(7.2per 30 days)

MOzafirlukast 2 QL(180 per

90 days)MO

ZYFLO CR 4 QL(360 per90 days)

MO

UROLOGICALSANTICHOLINERGICS /ANTISPASMODICSDETROL 3 QL(180 per

90 days)MO

DETROL LA 3 QL(90 per90 days)

MOENABLEX 3 QL(90 per

90 days)MO

flavoxate hcl 2 MO

GELNIQUE 3 QL(90 per90 days)

MOoxybutynin er tb24 5mg 1 QL(90 per

90 days)MO

oxybutynin er tb24 10mg, 15mg 1 QL(180 per90 days)

MOoxybutynin syrp 1 MO

Require-Drug Drug ments/Name Tier Limitsoxybutynin tabs 1 QL(360 per

90 days)MO

OXYTROL 3 QL(32 per90 days)

MOTOVIAZ 3 QL(90 per

90 days)MO

trospium chloride 2 QL(180 per90 days)

MOVESICARE 3 QL(90 per

90 days)MO

BENIGN PROSTATICHYPERPLASIA(BPH) THERAPYAVODART 3 QL(90 per

90 days)MO

finasteride 2 QL(90 per90 days)

MOJALYN 3 QL(90 per

90 days)MO

RAPAFLO 3 QL(90 per90 days)

MOtamsulosin hcl 2 QL(180 per

90 days)MO

UROXATRAL 3 QL(90 per90 days)

MO

CHOLINERGIC STIMULANTSbethanechol chloride 2 MO

MISCELLANEOUS UROLOGICALSCYSTAGON 3 LA

ELMIRON 3 MO

potassium citrate extended- 2 MOrelease

VITAMINS, HEMATINICS /ELECTROLYTESELECTROLYTES

33

Require-Drug Drug ments/Name Tier Limitscalcium acetate 2 MO

eliphos 2 MO

K-TABS 4 MO

kcl 0.075%/d5w/nacl 0.45% 2

kcl 0.15%/d5w/lr 2

KCL 0.15%/D5W/NACL 0.2% 3

KCL 0.15%/D5W/NACL 0.225% 3

kcl 0.15%/d5w/nacl 0.9% 2

kcl 0.3%/d5w/lr iv lac ring 2

KCL 0.3%/D5W/NACL 0.2% 3

kcl 0.3%/d5w/nacl 0.45% 2

kcl 0.3%/d5w/nacl 0.9% 2

klor-con 10 2 MO

klor-con 8 2 MO

KLOR-CON M15 4 MO

klor-con m20 2 MO

LACTATED RINGERS 3 MO

MAGNESIUM SULFATE IN 3D5W INJ 5%; 10MG/MLMAGNESIUM SULFATE INJ 3

NORMOSOL 3

POTASSIUM CHLORIDE 30.075%/D5W/NACL 0.225%POTASSIUM CHLORIDE 0.15% 3/NACL 0.45% VIAFLEXpotassium chloride 0.15% 2d5w/nacl 0.33%potassium chloride 0.15% 2 MOd5w/nacl 0.45% viaflexpotassium chloride 0.15% nacl 20.9%POTASSIUM CHLORIDE 30.15%/D5WPOTASSIUM CHLORIDE 0.22% 3D5W/NACL 0.45%potassium chloride 0.224%/d5w 2

POTASSIUM CHLORIDE 0.3%/ 3NACL 0.9%potassium chloride 0.3%/d5w 2

potassium chloride er cpcr 2 MO

potassium chloride er tbcr 10meq 2

potassium chloride er tbcr 20meq 2 MO

Require-Drug Drug ments/Name Tier Limitspotassium chloride inj 210meq/100ml, 10meq/50ml,2meq/mlPOTASSIUM CHLORIDE INJ 30.4MEQ/ML, 30MEQ/100MLringers injection 2

sodium bicarbonate inj 7.5%, 28.4%sodium chloride 0.45% viaflex 2 MO

sodium chloride inj 3%, 5% 2

sodium chloride inj 2.5meq/ml 2 MO

MISCELLANEOUS NUTRITIONPRODUCTSAMINOSYN 3

AMINOSYN II 3

AMINOSYN II M 3

AMINOSYN-HBC 3

AMINOSYN-HF 3

AMINOSYN-PF 3

AMINOSYN-PF 7% 3

CLINIMIX / DEXTROSE 3

CLINISOL SF 3

DEXTROSE 5% 3/ELECTROLYTE #48 VIAFLEXFREAMINE III 3

HEPATAMINE 3

HEPATASOL 3

INTRALIPID INJ 1.7%; 30% 3

intralipid inj 2.25%; 20% 2

IONOSOL 3

ISOLYTE 3

KCL 0.15%/D10W/NACL 0.2% 3

LIPOSYN III INJ 1.8%; 2.5%; 330%NEPHRAMINE 3

NORMOSOL 3

PLASMA-LYTE 3

34

Require-Drug Drug ments/Name Tier LimitsPREMASOL INJ 56MEQ/L; 3320MG/100ML; 730MG/100ML;190MG/100ML; 3MEQ/L;20MG/100ML; 300MG/100ML;220MG/100ML; 290MG/100ML;490MG/100ML; 840MG/100ML;490MG/100ML; 200MG/100ML;290MG/100ML; 410MG/100ML;230MG/100ML; 5MEQ/L;15MG/100ML; 250MG/100ML;120MG/100ML; 140MG/100ML;470MG/100MLpremasol inj 52meq/l; 21760mg/100ml; 880mg/100ml;34meq/l; 1760mg/100ml;372mg/100ml; 406mg/100ml;526mg/100ml; 492mg/100ml;492mg/100ml; 526mg/100ml;356mg/100ml; 356mg/100ml;390mg/100ml; 34mg/100ml;152mg/100mlTRAVASOL 3

TROPHAMINE 3

VITAMINS / HEMATINICSprenatal vitamins (generic) 1

sodium fluoride tabs 2 MO

35

Index of Drugs

8

8-MOP................................................................. 17

A

ABILIFY ....................................................... 10, 11

ABILIFY DISCMELT ........................................ 10

ABRAXANE......................................................... 5

acarbose .............................................................. 21

acebutolol ............................................................ 14

acetaminophen / codeine ....................................... 9

acetaminophen/codeine #3.................................... 9

acetaminophen/codeine #4.................................... 9

acetasol hc........................................................... 20

acetazolamide...................................................... 29

acetazolamide sodium ......................................... 29

acetic acid ........................................................... 20

acetic acid / hydrocortisone ................................ 20

acetylcysteine ...................................................... 31

ACTHIB.............................................................. 26

acticin .................................................................. 19

ACTIMMUNE .................................................... 25

ACTONEL .................................................... 19, 27

ACTOPLUS MET............................................... 21

ACTOS................................................................ 21

ACUVAIL........................................................... 29

acyclovir ................................................................ 1

ADACEL............................................................. 26

ADAGEN............................................................ 19

adapalene ............................................................ 18

adriamycin............................................................. 5

ADVAIR DISKUS.............................................. 31

ADVAIR HFA .................................................... 31

afeditab cr ........................................................... 14

AFINITOR ............................................................ 5

AGGRENOX ...................................................... 16

a-hydrocort.......................................................... 20

ak-con .................................................................. 30

ak-tob................................................................... 29

ala cort ................................................................ 18

ALBENZA ............................................................ 3

albuterol sulfate................................................... 31

albuterol sulfate er .............................................. 31

alclometasone dipropionate.................................18

ALCOHOL PREPS..............................................21

ALDURAZYME..................................................23

alendronate sodium........................................19, 27

ALIMTA................................................................5

ALINIA..................................................................3

ALKERAN ............................................................5

allopurinol............................................................27

ALOCRIL ............................................................29

ALORA................................................................27

ALPHAGAN P ....................................................30

ALREX ................................................................30

ALTABAX ..........................................................18

amantadine.............................................................1

amcinonide ...........................................................18

a-methapred .........................................................20

amifostine ...............................................................4

amikacin sulfate .....................................................3

amiloride ..............................................................14

amiloride/hydrochlorothiazide ............................14

aminophylline.......................................................31

AMINOSYN........................................................33

AMINOSYN II ....................................................33

AMINOSYN II M................................................33

AMINOSYN-HBC ..............................................33

AMINOSYN-HF..................................................33

AMINOSYN-PF ..................................................33

AMINOSYN-PF 7%............................................33

amiodarone ..........................................................13

AMITIZA.............................................................24

amitriptyline .........................................................11

amlodipine............................................................14

amlodipine / benazepril........................................14

ammonium lactate ................................................17

amnesteem............................................................18

amoxapine ............................................................11

amoxicillin..............................................................3

amoxicillin/clavulanate potassium.........................3

amoxicillin/clavulanate potassium er ....................3

amoxicillin/potassium clavulanate.........................4

amphotericin b .......................................................1

ampicillin ...............................................................4

36

ampicillin-sulbactam ............................................. 4

AMTURNIDE..................................................... 14

ANADROL-50 .................................................... 23

anagrelide hydrochloride .................................... 19

anastrozole ............................................................ 5

ANCOBON ........................................................... 1

ANDRODERM ................................................... 23

ANDROGEL....................................................... 23

ANDROGEL PUMP........................................... 23

ANDROID .......................................................... 23

androxy................................................................ 23

ANTABUSE........................................................ 19

APOKYN .............................................................. 8

apraclonidine ...................................................... 30

apri ...................................................................... 28

APTIVUS.............................................................. 1

ARALAST NP .................................................... 19

aranelle................................................................ 28

ARANESP........................................................... 25

ARCALYST........................................................ 25

ARICEPT .............................................................. 8

ARICEPT ODT..................................................... 8

ARIXTRA ........................................................... 16

ARRANON ........................................................... 5

ARTHROTEC 50................................................ 10

ARTHROTEC 75................................................ 10

ARZERRA ............................................................ 5

ASACOL............................................................. 24

ASACOL HD ...................................................... 24

ascomp/codeine ..................................................... 9

ASMANEX 120 METERED DOSES ................ 31

ASMANEX 14 METERED DOSES................... 31

ASMANEX 30 METERED DOSES................... 31

ASMANEX 60 METERED DOSES................... 31

ASTEPRO ........................................................... 20

atenolol................................................................ 14

atenolol / chlorthalidone ..................................... 14

ATRIPLA.............................................................. 1

atropine sulfate.................................................... 23

ATROVENT HFA .............................................. 31

augmented betamethasone dipropionate....... 18, 19

AVANDAMET ................................................... 21

AVANDARYL.................................................... 21

AVANDIA...........................................................21

AVASTIN..............................................................5

AVELOX ...............................................................4

AVELOX ABC PACK ..........................................4

aviane ...................................................................28

avita......................................................................18

AVODART..........................................................32

AVONEX.............................................................25

AZACTAM............................................................3

AZACTAM IN ISO-OSMOTIC DEXTROSE......3

AZASITE.............................................................29

azathioprine ...........................................................5

azathioprine sodium...............................................5

azelastine hcl..................................................20, 29

AZELEX..............................................................18

AZILECT...............................................................8

azithromycin...........................................................2

AZOPT.................................................................30

aztreonam...............................................................3

B

bacitracin .............................................................29

bacitracin / polymyxin b.......................................29

baclofen..................................................................9

BACTROBAN.....................................................18

BACTROBAN NASAL.......................................20

balsalazide ...........................................................24

balziva ..................................................................28

BANZEL................................................................7

BARACLUDE .......................................................1

BD INSULIN SYRINGE

SAFETYGLIDE/1ML/29G X 1/2 ...................21

BD INSULIN SYRINGE

ULTRAFINE/0.3ML/31G X 5/16 ...................21

BD INSULIN SYRINGE

ULTRAFINE/0.5ML/30G X 1/2 .....................21

BD INSULIN SYRINGE ULTRAFINE/1ML/31G

X 5/16...............................................................21

BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM

..........................................................................21

benazepril.............................................................14

benazepril / hydrochlorothiazide .........................14

benztropine mesylate..............................................8

37

BEPREVE ........................................................... 29

BESIVANCE ...................................................... 29

betamethasone dipropionate ............................... 19

betamethasone valerate....................................... 19

BETASERON ..................................................... 25

betaxolol hcl .................................................. 14, 29

bethanechol chloride ........................................... 32

BETOPTIC-S ...................................................... 29

bicalutamide .......................................................... 5

BICILLIN C-R ...................................................... 4

BICILLIN L-A ...................................................... 4

BICNU .................................................................. 5

BIDIL .................................................................. 14

BILTRICIDE......................................................... 3

bisoprolol fumarate ............................................. 14

bisoprolol fumarate / hydrochlorothiazide ......... 14

bleomycin sulfate................................................... 5

BLEPH-10........................................................... 30

BONIVA ............................................................. 27

BOOSTRIX......................................................... 26

brimonidine tartrate ............................................ 30

BROMDAY ........................................................ 29

bromfenac............................................................ 29

bromocriptine mesylate ......................................... 8

budeprion sr ........................................................ 11

budeprion xl......................................................... 11

budesonide........................................................... 31

bumetanide .......................................................... 14

BUPHENYL........................................................ 19

BUPRENEX.......................................................... 9

buprenorphine hcl ................................................. 9

buproban ............................................................. 20

bupropion hcl ...................................................... 11

bupropion hcl sr .................................................. 11

buspirone hcl ....................................................... 11

BUSULFEX .......................................................... 5

butorphanol tartrate............................................ 10

BYETTA ............................................................. 21

BYSTOLIC ......................................................... 14

C

cabergoline.......................................................... 23

CADUET............................................................. 17

calcipotriene ........................................................17

calcitonin-salmon.................................................23

calcitriol ...............................................................23

calcium acetate ....................................................33

camila...................................................................27

CAMPATH............................................................5

CAMPRAL ..........................................................19

CANASA .............................................................24

CAPASTAT SULFATE ........................................3

CAPEX ................................................................19

captopril ...............................................................14

captopril/hydrochlorothiazide .............................14

CARAC................................................................17

CARAFATE ........................................................25

carbamazepine .......................................................7

carbamazepine er...................................................7

CARBATROL .......................................................7

carbidopa / levodopa .............................................8

carbidopa/levodopa cr ...........................................8

carbidopa/levodopa odt .........................................8

carbidopa/levodopa sr ...........................................8

carbinoxamine maleate ........................................30

carboplatin .............................................................5

CARMOL-HC......................................................17

carteolol hcl .........................................................29

cartia xt ................................................................14

carvedilol .............................................................14

CAYSTON.............................................................3

CEENU ..................................................................5

cefaclor ..................................................................2

cefadroxil ...............................................................2

cefazolin .................................................................2

cefdinir ...................................................................2

cefepime .................................................................2

cefotaxime sodium..................................................2

cefoxitin sodium .....................................................2

cefpodoxime proxetil ..............................................2

ceftazidime .............................................................2

ceftriaxone sodium .................................................2

cefuroxime axetil ....................................................2

cefuroxime sodium .................................................2

CELEBREX.........................................................10

CELLCEPT............................................................5

38

CELLCEPT INTRAVENOUS.............................. 5

CELONTIN........................................................... 7

cephalexin.............................................................. 2

CEREZYME ....................................................... 23

CERVARIX ........................................................ 26

cesia..................................................................... 28

cetirizine hcl ........................................................ 30

CHANTIX........................................................... 20

CHEMET ............................................................ 19

chlordiazepoxide/amitriptyline............................ 11

chlorhexidine gluconate oral rinse ..................... 20

chloroquine............................................................ 3

chlorothiazide...................................................... 14

chlorothiazide sodium ......................................... 14

chlorpromazine.................................................... 11

chlorthalidone ..................................................... 14

cholestyramine light ............................................ 17

ciclopirox............................................................. 18

ciclopirox nail lacquer ........................................ 18

ciclopirox olamine............................................... 18

cilostazol.............................................................. 16

CILOXAN........................................................... 29

CIMZIA............................................................... 24

CIPRO HC........................................................... 20

CIPRO I.V.-IN D5W............................................. 4

CIPRODEX......................................................... 20

ciprofloxacin.................................................... 4, 29

cisplatin ................................................................. 5

citalopram ........................................................... 11

cladribine .............................................................. 5

claravis ................................................................ 18

CLARINEX......................................................... 30

CLARINEX REDITABS .................................... 30

CLARINEX-D 12 HOUR ................................... 30

CLARINEX-D 24 HOUR ................................... 30

clarithromycin ....................................................... 2

clarithromycin er................................................... 2

clemastine fumarate ............................................ 30

CLEOCIN............................................................ 28

CLEOCIN GALAXY............................................ 3

CLEOCIN PEDIATRIC GRANULES ................. 3

CLIMARA PRO.................................................. 27

clindamycin hcl ..................................................... 3

clindamycin phosphate...................................18, 28

clindamycin phosphate add-vantage......................3

clindamycin/benzoyl peroxide..............................18

CLINIMIX / DEXTROSE .............................19, 33

CLINISOL SF......................................................33

clobetasol propionate...........................................19

clobetasol propionate e........................................19

CLOBEX..............................................................19

CLOLAR................................................................5

clomipramine .......................................................11

clonidine...............................................................14

clotrimazole......................................................1, 18

clotrimazole / betamethasone ..............................18

clozapine ..............................................................11

COARTEM............................................................3

codeine sulfate .......................................................9

COLCRYS ...........................................................27

colestipol ..............................................................17

colistimethate sodium.............................................3

COLY-MYCIN S.................................................20

COMBIGAN........................................................30

COMBIPATCH ...................................................27

COMBIVENT......................................................31

COMBIVIR............................................................1

compro .................................................................24

COMTAN ..............................................................8

COMVAX............................................................26

CONDYLOX .......................................................17

constulose.............................................................24

COPAXONE..........................................................8

CORDRAN TAPE...............................................19

COREG CR..........................................................14

CORTIFOAM......................................................24

cortisone acetate ..................................................20

CORTISPORIN-TC.............................................20

cortomycin............................................................20

COSMEGEN..........................................................5

CREON................................................................24

CRESTOR............................................................17

CRINONE............................................................27

CRIXIVAN............................................................1

cromolyn sodium ............................................29, 31

cryselle-28............................................................28

39

CUBICIN .............................................................. 3

CUPRIMINE....................................................... 27

cyclafem 1/35....................................................... 28

cyclafem 7/7/7 ..................................................... 28

cyclobenzaprine hcl............................................... 9

cyclophosphamide ................................................. 5

cyclosporine .......................................................... 5

CYKLOKAPRON............................................... 16

CYMBALTA ...................................................... 11

CYSTADANE..................................................... 24

CYSTAGON ....................................................... 32

cytarabine.............................................................. 5

CYTARABINE AQUEOUS................................. 5

D

dacarbazine ........................................................... 5

DACOGEN ........................................................... 5

danazol ................................................................ 23

dantrolene sodium ................................................. 9

DAPSONE ............................................................ 3

DAPTACEL........................................................ 26

DARAPRIM.......................................................... 3

daunorubicin hcl ................................................... 5

DAUNOXOME..................................................... 5

DECAVAC.......................................................... 26

demeclocycline hcl ................................................ 4

DEMSER............................................................. 14

DENAVIR........................................................... 18

depade ................................................................. 10

DEPEN TITRATABS......................................... 27

DEPO-MEDROL ................................................ 20

DEPO-PROVERA .............................................. 27

DEPO-SUBQ PROVERA 104............................ 27

DERMA-SMOOTHE / FS BODY OIL .............. 19

DERMOTIC........................................................ 20

desipramine ......................................................... 11

desmopressin acetate........................................... 23

desonide............................................................... 19

desoximetasone.................................................... 19

DETROL ............................................................. 32

DETROL LA....................................................... 32

dexamethasone .............................................. 20, 30

DEXAMETHASONE INTENSOL .................... 20

DEXILANT .........................................................25

dexrazoxane ...........................................................4

dextroamphetamine sulfate ..................................11

dextroamphetamine sulfate er..............................11

DEXTROSE 10%/NACL 0.45%........................19

DEXTROSE 5% /ELECTROLYTE #48

VIAFLEX ........................................................33

dextrose 10% flex container.................................19

DEXTROSE 10%/NACL 0.2%...........................19

dextrose 2.5%/sodium chloride 0.45% ................19

dextrose 5%..........................................................19

dextrose 5%/nacl 0.2% ........................................19

dextrose 5%/nacl 0.225% ....................................19

DEXTROSE 5%/NACL 0.33%...........................19

dextrose 5%/nacl 0.45% ......................................19

dextrose 5%/nacl 0.9% ........................................19

DIBENZYLINE...................................................14

diclofenac potassium............................................10

diclofenac sodium ..........................................10, 29

diclofenac sodium ec............................................10

diclofenac sodium xr ............................................10

dicloxacillin sodium ...............................................4

dicyclomine hcl ..............................................23, 24

didanosine ..............................................................1

DIFFERIN............................................................18

diflorasone diacetate............................................19

DIFLUCAN IN NACL ..........................................1

diflunisal ..............................................................10

digoxin..................................................................16

dihydroergotamine mesylate ..................................8

DILANTIN ............................................................7

DILANTIN INFATABS........................................7

DILAUDID............................................................9

DILAUDID-5.........................................................9

DILAUDID-HP......................................................9

dilt-cd ...................................................................14

diltiazem cd ..........................................................14

diltiazem hcl .........................................................14

diltiazem hcl er.....................................................14

dilt-xr....................................................................14

diltzac ...................................................................14

DIOVAN..............................................................14

DIOVAN HCT.....................................................14

40

DIPENTUM ........................................................ 24

DIPHTHERIA/TETANUS TOXOID PEDIATRIC

......................................................................... 26

disopyramide phosphate...................................... 13

divalproex sodium ................................................. 7

divalproex sodium er ............................................. 7

DIVIGEL............................................................. 27

DOCETAXEL....................................................... 5

donepezil hcl.......................................................... 8

dorzolamide hcl ................................................... 30

dorzolamide hcl/timolol maleate ......................... 30

doxazosin ............................................................. 14

doxepin ................................................................ 11

DOXIL .................................................................. 5

doxorubicin hcl...................................................... 5

doxycycline hyclate ............................................... 4

doxycycline monohydrate ...................................... 4

dronabinol ........................................................... 24

DROXIA ............................................................... 5

DUETACT .......................................................... 21

DULERA............................................................. 31

duramorph ............................................................. 9

DUREZOL .......................................................... 30

E

e.e.s. 400................................................................ 2

E.E.S. GRANULES .............................................. 2

econazole nitrate ................................................. 18

EDECRIN............................................................ 14

EDURANT............................................................ 1

EFFIENT............................................................. 16

ELIDEL............................................................... 17

eliphos ................................................................. 33

ELITEK................................................................. 4

ELIXOPHYLLIN................................................ 31

ELLA................................................................... 28

ELLENCE ............................................................. 5

ELMIRON........................................................... 32

ELOXATIN........................................................... 5

ELSPAR................................................................ 5

EMBEDA.............................................................. 9

EMCYT................................................................. 5

EMEND............................................................... 24

EMSAM...............................................................11

EMTRIVA .............................................................1

ENABLEX...........................................................32

enalapril ...............................................................14

enalapril / hydrochlorothiazide .....................14, 15

ENBREL..............................................................27

endocet ...................................................................9

ENGERIX-B........................................................26

enoxaparin sodium...............................................16

enpresse-28 ..........................................................28

ENTOCORT EC ..................................................24

enulose .................................................................24

epinastine hcl .......................................................29

epinephrine hcl.....................................................30

EPIPEN................................................................30

EPIPEN-JR ..........................................................30

epirubicin hcl .........................................................5

epitol ......................................................................7

EPIVIR...................................................................1

EPIVIR HBV .........................................................1

eplerenone............................................................15

EPOGEN........................................................25, 26

EPZICOM..............................................................1

EQUETRO.............................................................7

ERAXIS .................................................................1

ERBITUX ..............................................................5

ergotamine tartrate / caffeine ................................8

errin......................................................................27

ery ........................................................................18

ERY-TAB ..............................................................2

ERYTHROCIN LACTOBIONATE......................2

erythrocin stearate .................................................2

erythromycin ..................................................18, 29

erythromycin / benzoyl peroxide ..........................18

ERYTHROMYCIN BASE ....................................2

erythromycin ethylsuccinate ..................................2

erythromycin/sulfisoxazole ....................................2

ESTRADERM .....................................................28

estradiol ...............................................................28

estradiol / norethindrone acetate.........................28

ESTRING.............................................................28

estropipate............................................................28

ethambutol..............................................................3

41

ethosuximide.......................................................... 7

etidronate disodium............................................. 19

etodolac ............................................................... 10

ETOPOPHOS........................................................ 5

etoposide................................................................ 5

EURAX ............................................................... 19

EVISTA............................................................... 27

EVOXAC ............................................................ 19

EXALGO .............................................................. 9

EXELON............................................................... 8

exemestane ............................................................ 5

EXFORGE .......................................................... 15

EXFORGE HCT ................................................. 15

EXJADE........................................................ 19, 20

F

FABRAZYME .................................................... 23

famciclovir............................................................. 1

famotidine............................................................ 25

famotidine premixed ............................................ 25

FANAPT ............................................................. 11

FANAPT TITRATION PACK ........................... 11

FARESTON .......................................................... 5

FASLODEX.......................................................... 5

FAZACLO .......................................................... 11

FELBATOL .......................................................... 7

felodipine er......................................................... 15

fenofibrate ........................................................... 17

fenofibrate micronized......................................... 17

fenoprofen calcium .............................................. 10

fentanyl citrate....................................................... 9

fentanyl citrate oral transmucosal ........................ 9

fentanyl patches..................................................... 9

fexofenadine hcl................................................... 30

FINACEA............................................................ 18

finasteride............................................................ 32

FIRMAGON.......................................................... 5

flavoxate hcl ........................................................ 32

flecainide acetate................................................. 13

FLECTOR ........................................................... 10

FLOVENT DISKUS ........................................... 31

FLOVENT HFA.................................................. 31

fluconazole ............................................................ 1

fluconazole in dextrose ..........................................1

fludarabine phosphate ...........................................5

fludrocortisone acetate ........................................20

flunisolide.............................................................31

fluocinolone acetonide .........................................19

fluocinonide..........................................................19

fluocinonide emollient base .................................19

fluorometholone ...................................................30

FLUOROPLEX....................................................17

fluorouracil ......................................................5, 17

fluoxetine..............................................................11

fluoxetine dr .........................................................11

fluphenazine .........................................................11

fluphenazine decanoate inj ..................................11

flurbiprofen ..........................................................10

flurbiprofen sodium..............................................29

flutamide ................................................................5

fluticasone propionate ...................................19, 31

fluvoxamine ..........................................................11

FML .....................................................................30

FML FORTE........................................................30

FOCALIN XR......................................................11

FORADIL AEROLIZER.....................................31

FORTAZ................................................................2

FORTEO..............................................................27

fortical..................................................................23

foscarnet sodium ....................................................1

fosinopril ..............................................................15

fosinopril / hydrochlorothiazide ..........................15

FOSRENOL.........................................................20

FRAGMIN ...........................................................16

FREAMINE III ....................................................33

furosemide............................................................15

FUZEON................................................................1

G

gabapentin..............................................................7

GABITRIL.............................................................7

galantamine hydrobromide ....................................8

ganciclovir .............................................................1

GARDASIL .........................................................26

GASTROCROM..................................................24

GAUZE PADS 2..................................................21

42

gavilyte-c ............................................................. 24

gavilyte-g ............................................................. 24

gavilyte-n/flavor pack.......................................... 24

GELNIQUE......................................................... 32

gemcitabine hcl ..................................................... 5

gemfibrozil........................................................... 17

gengraf .................................................................. 5

gentak .................................................................. 29

gentamicin sulfate ..................................... 3, 18, 29

gentamicin sulfate/0.9% sodium chloride ............. 3

gentamicin sulfate/sodium chloride ...................... 3

gentasol ............................................................... 29

GEODON............................................................ 11

gianvi ................................................................... 28

GILENYA ............................................................. 9

GLEEVEC............................................................. 5

glimepiride .......................................................... 21

glipizide ............................................................... 21

glipizide / metformin............................................ 21

glipizide er........................................................... 21

GLUCAGEN HYPOKIT .................................... 21

GLUCAGON EMERGENCY KIT..................... 21

glyburide.............................................................. 22

glyburide / metformin .................................... 21, 22

glyburide micronized........................................... 22

glycopyrrolate ..................................................... 24

glycron................................................................. 22

granisetron .......................................................... 24

griseofulvin microsize ........................................... 1

GRIS-PEG............................................................. 1

guanfacine hcl ..................................................... 15

GYNAZOLE-1.................................................... 28

H

HALAVEN............................................................ 5

HALDOL ............................................................ 11

HALDOL DECANOATE 100............................ 12

HALDOL DECANOATE 50.............................. 12

halobetasol propionate........................................ 19

haloperidol .......................................................... 12

haloperidol decanoate inj.................................... 12

haloperidol lactate inj ......................................... 12

HAVRIX ............................................................. 26

HEPARIN SODIUM ...........................................16

heparin sodium/d5w.............................................16

HEPARIN SODIUM/NACL 0.45% ....................16

heparin sodium/sodium chloride 0.9% premix ....16

HEPATAMINE....................................................33

HEPATASOL ......................................................33

HEPSERA..............................................................1

HERCEPTIN..........................................................5

HEXALEN.............................................................5

HIZENTRA..........................................................26

HUMALOG .........................................................22

HUMALOG KWIKPEN......................................22

HUMALOG MIX 50/50 ......................................22

HUMALOG MIX 50/50 KWIKPEN...................22

HUMALOG MIX 75/25 ......................................22

HUMALOG MIX 75/25 KWIKPEN...................22

HUMIRA .............................................................27

HUMIRA PEN-CROHNS DISEASE STARTER

..........................................................................27

HUMULIN 70/30.................................................22

HUMULIN 70/30 PEN........................................22

HUMULIN N.......................................................22

HUMULIN N U-100 PEN...................................22

HUMULIN R.......................................................22

HUMULIN R U-500 (CONCENTRATED)........22

hydralazine...........................................................15

hydrochlorothiazide .............................................15

hydrocodone bitartrate/acetaminophen.................9

hydrocodone/acetaminophen .................................9

hydrocodone/ibuprofen ..........................................9

hydrocortisone .........................................19, 20, 24

hydrocortisone butyrate .......................................19

hydrocortisone valerate .......................................19

hydromorphone hcl ................................................9

hydroxychloroquine ...............................................3

hydroxyurea ...........................................................5

hydroxyzine hcl ....................................................30

I

ibuprofen ..............................................................10

idarubicin hcl .........................................................5

IFEX.......................................................................5

ifosfamide ...............................................................5

43

ifosfamide/mesna ................................................... 5

imipramine .......................................................... 12

imipramine pamoate............................................ 12

imiquimod............................................................ 18

IMOVAX RABIES (H.D.C.V.) .......................... 26

INCRELEX ......................................................... 20

indapamide .......................................................... 15

indomethacin ....................................................... 10

indomethacin er................................................... 10

INFANRIX.......................................................... 26

INFUMORPH 200 ................................................ 9

INFUMORPH 500 ................................................ 9

INTELENCE......................................................... 1

INTRALIPID ...................................................... 33

INTRON-A.......................................................... 26

INTRON-A WITH DILUENT............................ 26

INVEGA.............................................................. 12

INVEGA SUSTENNA........................................ 12

INVIRASE ............................................................ 1

IONOSOL ........................................................... 33

IOPIDINE............................................................ 30

IPOL INACTIVATED IPV ................................ 26

ipratropium bromide ..................................... 20, 31

ipratropium bromide/albuterol sulfate................ 31

irinotecan .............................................................. 5

ISENTRESS.......................................................... 1

ISOLYTE ............................................................ 33

isonarif .................................................................. 3

ISONIAZID........................................................... 3

isosorbide dinitrate ............................................. 17

isosorbide dinitrate er ......................................... 17

isosorbide mononitrate........................................ 17

isosorbide mononitrate er ................................... 17

isotonic gentamicin ............................................... 3

isradipine............................................................. 15

ISTALOL ............................................................ 29

ISTODAX ............................................................. 5

itraconazole ........................................................... 1

IXEMPRA KIT ..................................................... 6

IXIARO............................................................... 26

J

JALYN ................................................................ 32

jantoven................................................................16

JANUMET...........................................................22

JANUVIA ............................................................22

JE-VAX................................................................26

JEVTANA..............................................................6

jinteli ....................................................................28

jolivette.................................................................28

junel......................................................................28

junel fe 1.5/30.......................................................28

junel fe 1/20..........................................................28

K

KADIAN................................................................9

KALETRA.............................................................1

kariva ...................................................................28

kcl 0.075%/d5w/nacl 0.45% ................................33

KCL 0.15%/D10W/NACL 0.2% .........................33

kcl 0.15%/d5w/lr ..................................................33

KCL 0.15%/D5W/NACL 0.2% ...........................33

KCL 0.15%/D5W/NACL 0.225% .......................33

kcl 0.15%/d5w/nacl 0.9% ....................................33

kcl 0.3%/d5w/lr iv lac ring...................................33

KCL 0.3%/D5W/NACL 0.2% .............................33

kcl 0.3%/d5w/nacl 0.45% ....................................33

kcl 0.3%/d5w/nacl 0.9% ......................................33

kelnor 1/35 ...........................................................28

KETEK ..................................................................3

ketoconazole.....................................................1, 18

ketoprofen ............................................................10

ketoprofen er ........................................................10

ketorolac tromethamine .......................................29

kionex ...................................................................20

klor-con 10 ...........................................................33

klor-con 8 .............................................................33

KLOR-CON M15 ................................................33

klor-con m20 ........................................................33

KOMBIGLYZE XR.............................................22

K-TABS ...............................................................33

KUVAN ...............................................................23

L

labetalol ...............................................................15

laclotion ...............................................................18

LACRISERT........................................................29

44

LACTATED RINGERS...................................... 33

lactulose .............................................................. 24

LAMICTAL ODT................................................. 7

LAMICTAL XR.................................................... 7

lamotrigine ............................................................ 7

LANOXIN........................................................... 16

lansoprazole ........................................................ 25

lansoprazole odt .................................................. 25

LANTUS ............................................................. 22

LANTUS SOLOSTAR ....................................... 22

latanoprost .......................................................... 30

LATUDA ............................................................ 12

leena .................................................................... 28

leflunomide .......................................................... 27

lessina-28 ............................................................ 28

LETAIRIS ........................................................... 31

letrozole ................................................................. 6

leucovorin calcium ................................................ 4

LEUKERAN ......................................................... 6

LEUKINE............................................................ 26

leuprolide acetate .................................................. 6

LEVAQUIN .......................................................... 4

levetiracetam ......................................................... 7

levobunolol hcl .................................................... 29

levocarnitine........................................................ 20

levocetirizine dihydrochloride............................. 30

levofloxacin ......................................................... 29

levora................................................................... 28

levorphanol tartrate .............................................. 9

levothyroxine ....................................................... 23

levoxyl.................................................................. 23

LEXAPRO .......................................................... 12

LEXIVA................................................................ 1

lidocaine .............................................................. 18

lidocaine / prilocaine .......................................... 18

lidocaine viscous ................................................. 18

LIDODERM........................................................ 18

LINDANE ........................................................... 19

liothyronine sodium............................................. 23

lipitor................................................................... 17

LIPOSYN III ....................................................... 33

lisinopril .............................................................. 15

lisinopril/hydrochlorothiazide............................. 15

lithium carbonate .................................................12

lithium carbonate er.............................................12

lithium citrate.......................................................12

LOCOID ..............................................................19

LODOSYN ............................................................8

loperamide hcl .....................................................24

losartan potassium ...............................................15

losartan potassium/hydrochlorothiazide .............15

LOTEMAX..........................................................30

LOTRONEX........................................................24

lovastatin..............................................................17

LOVAZA .............................................................17

LOVENOX ..........................................................16

low-ogestrel..........................................................28

loxapine................................................................12

LUMIGAN...........................................................30

LUPRON DEPOT..................................................6

LUPRON DEPOT-PED.........................................6

lutera ....................................................................28

LUXIQ .................................................................19

LYRICA.................................................................7

LYSODREN ..........................................................6

LYSTEDA ...........................................................28

M

MACRODANTIN..................................................4

MAGNESIUM SULFATE ..................................33

MAGNESIUM SULFATE IN D5W ...................33

MALARONE.........................................................3

malathion .............................................................19

maprotiline ...........................................................12

margesic-h..............................................................9

MARPLAN..........................................................12

MATULANE .........................................................6

matzim la ..............................................................15

MAXALT ..............................................................8

MAXALT-MLT.....................................................8

mebendazole...........................................................3

meclizine hcl.........................................................24

meclofenamate sodium.........................................10

medroxyprogesterone acetate ..............................28

mefenamic acid ....................................................10

mefloquine hcl ........................................................3

45

MEGACE ES ........................................................ 6

megestrol acetate................................................... 6

meloxicam............................................................ 10

melphalan hydrochloride ...................................... 6

MENACTRA ...................................................... 26

MENOMUNE-A/C/Y/W-135 ............................. 26

MENOSTAR....................................................... 28

MENVEO............................................................ 26

MEPRON .............................................................. 3

mercaptopurine ..................................................... 6

meropenem ............................................................ 3

mesalamine.......................................................... 24

mesna..................................................................... 5

MESNEX .............................................................. 5

MESTINON .......................................................... 9

MESTINON TIMESPAN ..................................... 9

METADATE CD ................................................ 12

metaproterenol sulfate......................................... 31

metformin hcl....................................................... 22

metformin hcl er .................................................. 22

methadone hcl ....................................................... 9

methadose.............................................................. 9

methazolamide..................................................... 29

methenamine hippurate ......................................... 4

METHERGINE................................................... 29

methimazole......................................................... 21

methotrexate .......................................................... 6

methotrexate sodium ............................................. 6

methyclothiazide.................................................. 15

methylphenidate hcl............................................. 12

methylphenidate hydrochloride........................... 12

methylprednisolone ............................................. 21

methylprednisolone acetate................................. 20

methylprednisolone sodiumsuccinate.................. 21

metipranolol ........................................................ 29

metoclopramide ................................................... 24

metolazone........................................................... 15

metoprolol succinate er ....................................... 15

metoprolol tartrate .............................................. 15

metoprolol/hydrochlorothiazide.......................... 15

METROGEL ....................................................... 18

metronidazole .................................................. 3, 18

metronidazole in nacl 0.79%................................. 3

metronidazole vaginal..........................................28

mexiletine .............................................................13

MICARDIS ..........................................................15

MICARDIS HCT.................................................15

miconazole 3 ........................................................28

microgestin 1.5/30................................................28

microgestin 1/20...................................................28

microgestin fe.......................................................28

microgestin fe 1.5/30............................................28

midodrine .............................................................20

migergot .................................................................8

MIGRANAL..........................................................8

minocycline hcl ......................................................4

minocycline hcl er ..................................................4

minoxidil ..............................................................15

MIRAPEX ER .......................................................8

mirtazapine ..........................................................12

mirtazapine odt ....................................................12

misoprostol...........................................................25

mitomycin ...............................................................6

mitoxantrone hcl ....................................................6

M-M-R II W/DILUENT 10 DOSE......................26

moexipril ..............................................................15

moexipril/hydrochlorothiazide.............................15

mometasone furoate .............................................19

mononessa............................................................28

morphine sulfate.....................................................9

morphine sulfate er ................................................9

MOXEZA ............................................................29

MOZOBIL ...........................................................26

MULTAQ ............................................................13

mupirocin .............................................................18

MUSTARGEN.......................................................6

MYCOBUTIN .......................................................3

mycophenolate mofetil ...........................................6

MYFORTIC...........................................................6

MYTELASE ..........................................................9

N

nabumetone ..........................................................10

nadolol .................................................................15

nadolol/bendroflumethiazide ...............................15

nafcillin sodium......................................................4

46

NAFTIN .............................................................. 18

NAGLAZYME.................................................... 23

NALLPEN/DEXTROSE....................................... 4

naloxone .............................................................. 10

naltrexone............................................................ 10

NAMENDA .......................................................... 9

NAMENDA TITRATION PAK ........................... 9

naproxen.............................................................. 10

naproxen sodium ................................................. 10

naratriptan hcl....................................................... 8

NASONEX.......................................................... 31

NATACYN ......................................................... 29

nateglinide ........................................................... 22

NEBUPENT.......................................................... 3

necon 0.5/35-28 ................................................... 28

necon 1/35-28 ...................................................... 28

necon 10/11-28 .................................................... 28

necon 7/7/7 .......................................................... 28

nefazodone........................................................... 12

neomycin sulfate .................................................... 3

neomycin/bacitracin/polymyxin .......................... 29

neomycin/polymyxin/bacitracin/hydrocortisone . 30

neomycin/polymyxin/dexamethasone .................. 30

neomycin/polymyxin/gramicidin ......................... 29

neomycin/polymyxin/hc ....................................... 20

neomycin/polymyxin/hydrocortisone............. 20, 30

NEORAL............................................................... 6

NEPHRAMINE................................................... 33

NEULASTA........................................................ 26

NEUMEGA......................................................... 26

NEUPOGEN ....................................................... 26

NEVANAC ......................................................... 29

NEXAVAR ........................................................... 6

NEXIUM............................................................. 25

NEXIUM I.V....................................................... 25

next choice........................................................... 28

NIASPAN............................................................ 17

nicardipine .......................................................... 15

NICOTROL INHALER ...................................... 20

NICOTROL NASAL .......................................... 20

nifediac cc ........................................................... 15

nifedical xl ........................................................... 15

nifedipine ............................................................. 15

nifedipine er .........................................................15

NILANDRON........................................................6

nimodipine............................................................15

NIPENT .................................................................6

nisoldipine............................................................15

nisoldipine er .......................................................15

nitro-bid ...............................................................17

NITRO-DUR........................................................17

nitrofurantoin.........................................................4

nitrofurantoin macrocrystalline.............................4

nitrofurantoin monohydrate...................................4

nitroglycerin.........................................................17

nitroglycerin transdermal ....................................17

NITROLINGUAL PUMPSPRAY.......................17

NITROSTAT .......................................................17

nizatidine..............................................................25

nora-be .................................................................28

NORDITROPIN FLEXPRO................................26

NORDITROPIN NORDIFLEX PEN ..................26

norethindrone.......................................................28

NORMOSOL .......................................................33

NOROXIN .............................................................4

NORPACE CR.....................................................13

nortrel 0.5/35 (28)................................................28

nortrel 1/35 (21)...................................................28

nortrel 1/35 (28)...................................................28

nortrel 7/7/7 .........................................................28

nortriptyline .........................................................12

NORVIR ................................................................1

NOVOLOG..........................................................22

NOVOLOG FLEXPEN .......................................22

NOVOLOG MIX 70/30.......................................23

NOVOLOG MIX 70/30 PREFILLED FLEXPEN

..........................................................................23

NOXAFIL..............................................................1

NUEDEXTA..........................................................9

NUVARING ........................................................28

nyamyc .................................................................18

nystatin .............................................................1, 18

nystatin / triamcinolone .......................................18

nystop ...................................................................18

O

ocella ................................................................... 28

octreotide............................................................... 6

ofloxacin .................................................... 4, 20, 29

ogestrel ................................................................ 28

omeprazole .......................................................... 25

omeprazole/sodium bicarbonate ......................... 25

omnitrope ............................................................ 26

ondansetron hcl ................................................... 24

ondansetron odt................................................... 24

ONGLYZA.......................................................... 23

ONSOLIS .............................................................. 9

ONTAK................................................................. 6

OPANA ER........................................................... 9

ORAP .................................................................. 12

ORAVIG ............................................................... 1

ORFADIN ........................................................... 20

ORTHO EVRA ................................................... 28

ortho-est .............................................................. 28

oxaliplatin.............................................................. 6

oxandrolone......................................................... 23

oxaprozin ............................................................. 10

oxcarbazepine........................................................ 7

OXSORALEN ULTRA ...................................... 18

oxybutynin ........................................................... 32

oxybutynin er ....................................................... 32

oxycodone / acetaminophen ............................ 9, 10

oxycodone hcl ...................................................... 10

oxycodone/aspirin ............................................... 10

OXYCONTIN ..................................................... 10

oxymorphone hydrochloride ............................... 10

OXYTROL.......................................................... 32

P

PACERONE........................................................ 13

paclitaxel ............................................................... 6

palgic ................................................................... 30

PANDEL ............................................................. 19

PANRETIN ......................................................... 18

paromomycin ......................................................... 3

paroxetine............................................................ 12

paroxetine er ....................................................... 12

PASER .................................................................. 3

PATADAY ..........................................................29

PATANOL...........................................................29

PAXIL..................................................................12

pedi-dri.................................................................18

PEDVAX HIB .....................................................26

PEGANONE..........................................................7

PEGASYS............................................................26

PEG-INTRON......................................................26

PEG-INTRON REDIPEN....................................26

penicillin g potassium ............................................4

PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE.......................................................4

PENICILLIN G PROCAINE.................................4

PENICILLIN G SODIUM.....................................4

penicillin v potassium ............................................4

PENNSAID..........................................................10

PENTASA............................................................24

pentopak ...............................................................16

pentostatin..............................................................6

pentoxifylline er ...................................................16

PERFOROMIST..................................................31

perindopril erbumine ...........................................15

periogard..............................................................20

permethrin............................................................19

perphenazine ........................................................12

pfizerpen-g .............................................................4

phenadoz ..............................................................30

phenelzine sulfate.................................................12

phenytoin................................................................7

PHENYTOIN SODIUM........................................7

phenytoin sodium extended ....................................7

PHISOHEX..........................................................18

PHOTOFRIN .........................................................6

pilocarpine hcl .....................................................20

PILOPINE HS......................................................29

pindolol ................................................................15

piperacillin sodium/tazobactam sodium ................4

piroxicam .............................................................10

PLASMA-LYTE..................................................33

PLAVIX...............................................................16

podofilox ..............................................................18

poly-dex................................................................30

polyethylene glycol 3350......................................24

47

48

portia-28.............................................................. 28

potassium chloride .............................................. 33

POTASSIUM CHLORIDE 0.075%/D5W/NACL

0.225%............................................................. 33

POTASSIUM CHLORIDE 0.15% /NACL 0.45%

VIAFLEX........................................................ 33

potassium chloride 0.15% d5w/nacl 0.33% ........ 33

potassium chloride 0.15% d5w/nacl 0.45% viaflex

......................................................................... 33

potassium chloride 0.15% nacl 0.9%.................. 33

POTASSIUM CHLORIDE 0.15%/D5W............ 33

POTASSIUM CHLORIDE 0.22% D5W/NACL

0.45%............................................................... 33

potassium chloride 0.224%/d5w ......................... 33

POTASSIUM CHLORIDE 0.3%/ NACL 0.9% . 33

potassium chloride 0.3%/d5w ............................. 33

potassium chloride er .......................................... 33

potassium citrate extended-release ..................... 32

PRADAXA.......................................................... 16

pramipexole dihydrochloride ................................ 8

PRANDIN ........................................................... 23

pravastatin........................................................... 17

prazosin ............................................................... 16

prednicarbate ...................................................... 19

prednisolone acetate ........................................... 30

prednisolone sodium phosphate .................... 21, 30

prednisone ........................................................... 21

PREDNISONE INTENSOL ............................... 21

PREFEST ............................................................ 28

PREMARIN ........................................................ 28

PREMARIN W/APPLICATOR.......................... 28

PREMASOL........................................................ 34

PREMPHASE ..................................................... 28

PREMPRO .......................................................... 28

prenatal vitamins (generic) ................................. 34

prevalite............................................................... 17

previfem ............................................................... 28

PREVPAC........................................................... 25

PREZISTA ............................................................ 1

PRIMAQUINE...................................................... 3

PRIMAXIN I.M. ................................................... 3

PRIMAXIN IV...................................................... 3

primidone .............................................................. 7

PRIMSOL ..............................................................4

PRISTIQ ..............................................................12

PRIVIGEN...........................................................26

PROAIR HFA......................................................31

probenecid............................................................27

probenecid / colchicine ........................................27

procainamide .......................................................13

prochlorperazine..................................................24

prochlorperazine edisylate...................................24

prochlorperazine maleate ....................................24

PROCRIT.............................................................26

procto-pak ............................................................24

proctosol hc..........................................................24

proctozone-hc.......................................................24

PROGLYCEM.....................................................23

PROGRAF .............................................................6

PROLASTIN........................................................20

PROLASTIN-C....................................................20

PROLEUKIN.......................................................26

PROMACTA .................................................16, 17

promethazine hcl ............................................30, 31

promethegan ........................................................31

PROMETRIUM...................................................28

propafenone hcl ...................................................14

propafenone hcl er ...............................................14

propantheline bromide.........................................24

propranolol hcl ....................................................16

propranolol hcl er ................................................16

propranolol/hydrochlorothiazide.........................16

propylthiouracil ...................................................21

PROQUAD ..........................................................26

PROTOPIC ..........................................................18

protriptyline hcl ...................................................12

PROVIGIL...........................................................12

PULMICORT ......................................................31

PULMOZYME ....................................................31

PYLERA..............................................................25

pyrazinamide..........................................................3

pyridostigmine bromide .........................................9

Q

QUALAQUIN........................................................3

quasense ...............................................................28

49

quinapril .............................................................. 16

quinapril/hydrochlorothiazide ............................ 16

quinidine gluconate er......................................... 14

quinidine sulfate .................................................. 14

quinidine sulfate er.............................................. 14

R

RABAVERT ....................................................... 26

ramipril................................................................ 16

RANEXA ............................................................ 17

ranitidine hcl ....................................................... 25

RAPAFLO........................................................... 32

RAPAMUNE ........................................................ 6

REBETOL............................................................. 1

REBIF.................................................................. 26

REBIF TITRATION PACK ............................... 26

reclipsen .............................................................. 28

RECOMBIVAX HB ........................................... 27

regonol .................................................................. 9

REGRANEX ....................................................... 18

RELENZA DISKHALER..................................... 1

RELISTOR.......................................................... 24

RELPAX ............................................................... 8

REMICADE........................................................ 24

REMODULIN..................................................... 16

RENAGEL .......................................................... 20

RENVELA .......................................................... 20

reprexain ............................................................. 10

REQUIP XL .......................................................... 8

RESCRIPTOR....................................................... 1

reserpine.............................................................. 16

RESTASIS .......................................................... 29

RETROVIR IV INFUSION.................................. 1

REVATIO ........................................................... 31

REVLIMID ........................................................... 6

REYATAZ ............................................................ 1

RHEUMATREX ................................................... 6

ribapak .................................................................. 1

ribasphere.......................................................... 1, 2

ribavirin................................................................. 2

RIDAURA........................................................... 27

rifampin ................................................................. 3

RILUTEK............................................................ 20

rimantadine hcl ......................................................2

ringers injection ...................................................33

RISPERDAL CONSTA.......................................12

risperidone ...........................................................13

risperidone odt .....................................................12

RITALIN LA .......................................................13

RITUXAN..............................................................6

rivastigmine tartrate ..............................................9

romycin ................................................................29

ropinirole ...............................................................8

ROTATEQ...........................................................27

ROXICET ............................................................10

ROZEREM ..........................................................13

S

SABRIL .................................................................7

SAMSCA .............................................................23

SANCUSO...........................................................24

SANDIMMUNE....................................................6

SANDOSTATIN LAR DEPOT.............................6

SANTYL..............................................................19

SAPHRIS .............................................................13

SAVELLA ...........................................................27

SAVELLA TITRATION PACK .........................27

selegiline ................................................................8

selenium sulfide....................................................17

SELZENTRY.........................................................2

SENSIPAR...........................................................23

SEREVENT DISKUS..........................................31

SEROMYCIN........................................................3

SEROQUEL.........................................................13

SEROQUEL XR ..................................................13

sertraline ..............................................................13

SILENOR.............................................................13

silver sulfadiazine ................................................17

SIMPONI .............................................................27

SIMULECT............................................................6

simvastatin ...........................................................17

SINGULAIR........................................................31

SKELID ...............................................................20

sodium bicarbonate..............................................33

sodium chloride..............................................20, 33

sodium chloride 0.9% .........................................20

50

sodium chloride 0.45% viaflex ............................ 33

SODIUM EDECRIN........................................... 16

sodium fluoride.................................................... 34

sodium polystyrene sulfonate .............................. 20

sodium sulfacetamide .................................... 18, 30

SOLARAZE........................................................ 18

solia ..................................................................... 28

SOLU-CORTEF.................................................. 21

SOLU-MEDROL ................................................ 21

SOMATULINE DEPOT....................................... 6

SOMAVERT....................................................... 23

SORIATANE ...................................................... 17

sorine ................................................................... 14

sotalol .................................................................. 14

sotret.................................................................... 18

SPIRIVA HANDIHALER .................................. 31

spironolactone ..................................................... 16

spironolactone/hydrochlorothiazide ................... 16

SPORANOX ......................................................... 1

sprintec 28 ........................................................... 28

SPRYCEL ............................................................. 6

sronyx .................................................................. 28

ssd........................................................................ 17

stagesic ................................................................ 10

STALEVO 100...................................................... 8

STALEVO 125...................................................... 8

STALEVO 150...................................................... 8

STALEVO 200...................................................... 8

STALEVO 50........................................................ 8

STALEVO 75........................................................ 8

stavudine................................................................ 2

STIMATE............................................................ 23

STRATTERA...................................................... 13

STREPTOMYCIN SULFATE.............................. 3

STROMECTOL .................................................... 3

SUBOXONE ....................................................... 10

sucralfate ............................................................. 25

sulfacetamide sodium / prednisolone sodium

phospha ........................................................... 30

sulfadiazine............................................................ 4

sulfamethoxazole/trimethoprim ............................. 4

sulfamethoxazole/trimethoprim ds ........................ 4

SULFAMYLON.................................................. 18

sulfasalazine.........................................................24

sulfazine ec...........................................................24

sulindac ................................................................10

sumatriptan succinate ............................................8

SUPRAX................................................................2

SURMONTIL ......................................................13

SUSTIVA...............................................................2

SUTENT ................................................................6

SYMBICORT ......................................................31

SYMBYAX..........................................................13

SYMLIN ..............................................................23

SYMLINPEN 120................................................23

SYMLINPEN 60..................................................23

SYNAREL ...........................................................23

SYNTHROID ......................................................23

SYPRINE.............................................................20

T

TABLOID..............................................................6

tacrolimus ..............................................................6

TAMIFLU..............................................................2

tamoxifen citrate ....................................................6

tamsulosin hcl ......................................................32

TARCEVA.............................................................6

TARGRETIN.........................................................6

TASIGNA..............................................................6

TAXOTERE ......................................................6, 7

TAZICEF ...............................................................2

TAZORAC...........................................................18

taztia xt.................................................................16

TEFLARO..............................................................2

TEGRETOL-XR....................................................7

TEKAMLO..........................................................16

TEKTURNA........................................................16

TEKTURNA HCT...............................................16

terazosin hcl .........................................................16

terbinafine ..............................................................1

terbutaline sulfate ................................................32

terconazole ...........................................................28

testosterone cypionate..........................................23

testosterone enanthate .........................................23

TETANUS / DIPHTHERIA TOXOIDS-

ADSORBED ADULT .....................................27

51

TETANUS TOXOID ADSORBED.................... 27

tetracycline hcl ...................................................... 4

TEV-TROPIN ..................................................... 26

THALOMID.......................................................... 7

THEO-24............................................................. 32

theochron............................................................. 32

theophylline er..................................................... 32

thermazene .......................................................... 17

thioridazine.......................................................... 13

thiotepa.................................................................. 7

thiothixene ........................................................... 13

THYMOGLOBULIN.......................................... 27

ticlopidine hcl ...................................................... 17

TIKOSYN ........................................................... 14

timolol maleate .............................................. 16, 29

timolol maleate ophthalmic gel forming ............. 29

TIMOPTIC OCUDOSE ...................................... 29

tizanidine hcl ......................................................... 9

TOBI...................................................................... 3

TOBRADEX ....................................................... 30

TOBRADEX ST ................................................. 30

tobramycin....................................................... 3, 29

TOBRAMYCIN SULFATE / SODIUM

CHLORIDE....................................................... 3

tobramycin/dexamethasone ................................. 30

tobrasol................................................................ 29

TOBREX............................................................. 29

tolazamide ........................................................... 23

tolbutamide.......................................................... 23

tolmetin sodium ................................................... 10

topiramate ............................................................. 7

toposar................................................................... 7

topotecan hcl ......................................................... 7

TORISEL .............................................................. 7

torsemide ............................................................. 16

TOVIAZ.............................................................. 32

TRACLEER ........................................................ 32

tramadol .............................................................. 10

tramadol hcl er .................................................... 10

trandolapril ......................................................... 16

TRANSDERM-SCOP......................................... 24

tranylcypromine .................................................. 13

TRAVASOL........................................................ 34

TRAVATAN Z ....................................................30

trazodone..............................................................13

TREANDA ............................................................7

TRECATOR ..........................................................3

TRELSTAR DEPOT MIXJECT............................7

TRELSTAR LA MIXJECT ...................................7

TRELSTAR MIXJECT .........................................7

tretinoin............................................................7, 18

triamcinolone acetonide.......................................19

triamcinolone in orabase .....................................20

triamterene/hydrochlorothiazide .........................16

TRICOR...............................................................17

triderm..................................................................19

trifluoperazine......................................................13

trifluridine ............................................................29

trihexyphenidyl.......................................................8

tri-legest fe ...........................................................29

TRILIPIX.............................................................17

trilyte ....................................................................25

trimethoprim ..........................................................4

trimethoprim sulfate/polymyxin b sulfate.............29

trinessa .................................................................29

TRIPEDIA ...........................................................27

tri-previfem ..........................................................29

TRISENOX............................................................7

tri-sprintec............................................................29

trivora-28 .............................................................29

TRIZIVIR ..............................................................2

TROPHAMINE ...................................................34

tropicamide ..........................................................29

trospium chloride .................................................32

TRUVADA............................................................2

TWINJECT..........................................................31

TWINRIX ............................................................27

TWYNSTA..........................................................16

TYGACIL..............................................................3

TYKERB................................................................7

TYPHIM VI.........................................................27

TYZEKA................................................................2

TYZINE ...............................................................20

TYZINE PEDIATRIC NASAL DROPS.............20

52

U

ULESFIA ............................................................ 19

ULORIC.............................................................. 27

unithroid .............................................................. 23

UROXATRAL .................................................... 32

ursodiol................................................................ 25

UVADEX............................................................ 18

V

VAGIFEM........................................................... 28

valacyclovir hcl ..................................................... 2

VALCYTE ............................................................ 2

valproate sodium ................................................... 7

valproic acid.......................................................... 7

VALTURNA....................................................... 16

VANCOCIN ORAL.............................................. 4

vancomycin............................................................ 4

vandazole............................................................. 28

VANDETANIB..................................................... 7

VAQTA............................................................... 27

VARIVAX .......................................................... 27

VECTIBIX ............................................................ 7

VELCADE ............................................................ 7

velivet .................................................................. 29

venlafaxine hcl..................................................... 13

venlafaxine hcl er ................................................ 13

VENTOLIN HFA................................................ 32

VERAMYST....................................................... 32

verapamil............................................................. 16

verapamil er ........................................................ 16

VEREGEN .......................................................... 18

VESICARE ......................................................... 32

VFEND.................................................................. 1

VFEND IV ............................................................ 1

VIBATIV .............................................................. 4

VIBRAMYCIN ..................................................... 4

VIDAZA................................................................ 7

VIDEX PEDIATRIC............................................. 2

VIGAMOX.......................................................... 29

VIIBRYD ............................................................ 13

VIMOVO ............................................................ 10

VIMPAT............................................................ 7, 8

vinblastine sulfate.................................................. 7

vincasar pfs ............................................................7

vincristine sulfate ...................................................7

vinorelbine tartrate ................................................7

VIRACEPT............................................................2

VIRAMUNE..........................................................2

VIREAD ................................................................2

VIVAGLOBIN ....................................................27

VIVELLE-DOT ...................................................28

VOLTAREN........................................................10

voriconazole ...........................................................1

VOTRIENT............................................................7

W

warfarin................................................................17

WELCHOL..........................................................17

X

XENAZINE ...........................................................9

XGEVA..................................................................5

XIFAXAN..............................................................3

XOLAIR ..............................................................32

XYREM ...............................................................13

Y

YF-VAX ..............................................................27

Z

zafirlukast.............................................................32

zaleplon ................................................................13

ZANOSAR.............................................................7

ZANTAC .............................................................25

ZAVESCA ...........................................................23

zazole....................................................................28

ZELAPAR..............................................................8

ZEMPLAR...........................................................23

ZENPEP...............................................................25

zeosa.....................................................................29

zerlor ....................................................................10

ZETIA..................................................................17

ZIAGEN.................................................................2

zidovudine ..............................................................2

ZINACEF...............................................................2

ZINACEF IN ISO-OSMOTIC DEXTROSE.........2

ZINACEF IN ISO-OSMOTIC DILUENT ............2

53

ZINECARD........................................................... 5

ZIRGAN.............................................................. 29

ZMAX ................................................................... 2

ZOLINZA.............................................................. 7

zolpidem .............................................................. 13

zolpidem tartrate er ............................................. 13

ZOMETA ............................................................ 23

ZONALON.......................................................... 18

zonisamide ............................................................. 8

ZORTRESS........................................................... 7

ZOSTAVAX ....................................................... 27

ZOSYN.................................................................. 4

zovia 1/35e ...........................................................29

zovia 1/50e ...........................................................29

ZOVIRAX............................................................18

ZUPLENZ............................................................25

ZYFLO CR ..........................................................32

ZYLET.................................................................30

ZYMAR ...............................................................29

ZYMAXID...........................................................29

ZYPREXA ...........................................................13

ZYPREXA ZYDIS ..............................................13

ZYTIGA.................................................................7

ZYVOX..................................................................3

With Medco Medicare Prescription Plan® (PDP), you will have access to over 63,000 network pharmacies nationally. You may fill your prescriptions at a retail, home infusion, long-term care, Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) pharmacy, or through our convenient mail-order service.* In order to maximize your benefits, covered drugs must be filled at a network pharmacy. However, there are emergency circumstances under which you may be reimbursed for a formulary prescription that is not filled at a network pharmacy. Quantity limits, co-payments, and other restrictions may apply. For additional information, please contact us at the numbers listed on your Member ID card, 24 hours a day, 7 days a week, or visit us on the Web at www.medco.com.

*Other pharmacies are available in our network.

Medco Health Solutions, Inc., 100 Parsons Pond Drive, Franklin Lakes, NJ 07417

Medco and Medco Medicare Prescription Plan are registered trademarks of Medco Health Solutions, Inc. © 2011 Medco Health Solutions, Inc. All rights reserved.

F00SNV2A *F00

SNV2

A*